Reforming Prior Authorization Practices in Health Insurance

Amidst growing criticism, several leading health insurance companies in the United States have pledged to reduce their dependence on prior authorization, but concerns remain about meaningful change in practice.

Prior authorization, which requires extra approval before insurers cover medical treatments and procedures, has faced backlash from patients, healthcare providers, and lawmakers due to its potential to delay or deny necessary care. While some insurers have promised to overhaul this process, it continues to be a crucial tool for managing medical costs. Potential delays not only disrupt patient treatment but also lead to financial implications for insurers. ProPublica, a prominent investigative journalism organization, has launched an investigation led by Max Blau and Brandon Roberts to evaluate the impact of prior authorizations on patient care. The investigation seeks input from beneficiaries of Medicaid, CHIP, Affordable Care Act marketplace plans, and Medicare, aiming to gather firsthand accounts of delays or denials caused by prior authorizations.

The Impact of Prior Authorizations on Medicare

The prior authorization procedure is notably common in Medicare Advantage plans and is becoming increasingly utilized within traditional Medicare through programs like WISeR. This program, initiated by a previous administration, involves private technology firms to conduct prior authorization reviews for certain services. Such measures blur the lines between traditional Medicare and Medicare Advantage, sparking concerns about the shift in how traditional plans operate. ProPublica is keen to receive feedback from medical professionals and insurance industry workers involved with prior authorization procedures.

Post Hoc Payment Denials: An Additional Concern

Alongside the issue of prior authorizations, there is growing scrutiny of post hoc payment denials. These denials can occur even after prior authorization approvals, creating confusion and complications for patients at pharmacies where prescribed medications face approval barriers. ProPublica's investigation aims to uncover the lasting effects of these practices on patient care and healthcare delivery, distinguishing between denials related to drugs versus those concerning tests and procedures. Their report will shed light on the reality of insurance operations and highlight areas needing reform.