If you are enrolled in a health care plan or in a Medicare Advantage plan, it may require you to get prior authorization to see a specialist or to get anything more than a basic office visit. The companies that run these plans and require these prior authorizations defend them on the grounds that they eliminate wasteful visits, tests, and treatments. Patients and their advocates tell a different story, however. They say the companies use prior authorization requirements to discourage or deny needed care and save themselves billions in the process.
Even in a perfect world, prior authorization requirements would be burdensome and result in some care being delayed or denied. Sadly, we don’t live in a perfect world. The prior authorization requirements of the health plans are a mess. This is probably a feature of the system created by the plans and not a bug. The only people who like the current system are the health care plans themselves, which sometimes use the requirement of prior authorization to avoid paying meritorious claims. It is a commonly held belief, and one with more than a kernel of truth in it, that health care plans devote more resources to avoiding the payment of claims than they do to their actual payment.
The first problem for a patient and her doctor is to determine if prior authorization is even required for the planned treatment or procedure. This in and of itself can be a monumental task. Different companies have different ways of handling the process. Some accept electronic submissions, some only accept fax requests, while some require a telephone call, which may leave a doctor or hospital staffer on hold for long periods of time waiting to speak to “the next available agent.”
Once the doctor or hospital determines that prior authorization is required, the next question is what does this particular company require to demonstrate the medical necessity of the test, treatment or procedure? Different companies have different requirements. It takes time and effort by the health care provider to determine and then meet each company’s requirements.
Even if the provider does everything right in requesting authorization and the medical necessity of the treatment is clear, some health plans will still deny prior authorization. Sometimes this is the result of a mistake and sometimes it is not. The burden will usually then fall on the patient to decide whether to forego the treatment or to file and appeal with the company. Sometimes, of course, the treatment cannot be delayed. Then the poor patient must decide whether to commit to paying for the treatment herself, if the health plan denies the appeal, or to do without the treatment altogether. The health plans count on some of these patients to fall by the wayside and to do without the treatment. If there is an appeal, they will often fight it.
Patients are not the only ones who hate prior authorization requirements. Doctors and hospitals hate them as well. They use up tremendous amounts of resources of the providers for which they do not receive any compensation. Many medical practices and almost all hospitals have staffs dedicated to determining if prior authorization is required and obtaining it, if it is. It is not uncommon for a provider to be told that no prior authorization is required only to have the bill rejected by the plan because prior authorization was not obtained. Now there is still more paperwork necessary for the provider.
We are probably never going to get rid of prior authorization requirements. However, at a minimum, there should be a simple, standard, quick procedure used by all plans for determining the need for prior authorization and for obtaining it. Doctors and hospitals cannot be expected to continue to expend precious resources dealing with prior authorization issues. Patients should not be held hostage to prior authorization requirements that are not medically justified and are nothing more than profit centers for the health care plans.
