Meadville Times: Breaking down Healthcare Barriers: Fighting For Prior Authorization Reform
By Jennifer Riley, Patients Come First Pennsylvania’s Executive Director
Led by Congressman Mike Kelly, efforts to reform prior authorization are gaining momentum in Washington, and for good reason.
Prior authorization is a process used by health insurance companies to determine whether a prescribed procedure, service or medication will be covered. While it is intended to prevent unnecessary treatments and control costs, its current implementation is deeply flawed, especially for the Medicare population. It creates unnecessary obstacles for both health care providers and patients, delaying essential treatments and increasing administrative burdens.
In Pennsylvania, the situation is particularly dire. Physicians and health care professionals frequently find themselves tangled in outdated procedures, spending valuable time on unconfirmed faxes and endless phone calls rather than treating patients.
Prior authorization has become the number one administrative burden in health care, and its inefficiencies are causing real harm. Of the 1.4 million Medicare Advantage enrollees in Pennsylvania, over a million are enrolled in plans that have authorization requirements, A troubling statistic that underscores the urgent need for change.
Recent findings from the Office of the Inspector General at the U.S. Department of Health and Human Services (HHS) reveal a disturbing pattern: Medicare Advantage plans initially deny many claims only to approve them later upon appeal. In fact, an audit found that 75 percent of previously denied claims were ultimately approved. More troublingly, another HHS report found that many denials occurred despite patients meeting Medicare coverage requirements. This pattern suggests that prior authorization is being used as an unnecessary barrier to care rather than a legitimate means of cost control.
Leading health organizations have already established a consensus on the need for reform. Medical associations, patient advocacy groups, and bipartisan lawmakers can all agree that prior authorization policies need to be reined in to prevent unnecessary harm. Nearly one in four doctors say the practice of prior authorization has led to serious issues for patients. In some cases, these delays have resulted in permanent issues or loss of life.
American Medical Association President Bruce A. Scott, MD, recently shared the story of a “patient who had a tumor in his throat that we were concerned might be cancer.” The patient and his family had to wait “over two weeks for his insurance company to approve the biopsy so he could find out whether he had cancer of his throat or not.”
Delays like this represent life-altering obstacles for patients and their families. Scott emphasized the point — “the bottom line is prior authorization delays needed care and harms patients.” Without meaningful reform, these barriers will continue to put patient safety and well-being at risk.
Read the full op-ed in the Meadville Times.