Industry Voices—How prior authorization can disrupt medically necessary care

Health insurance form payer plan enroll
Doing your research is a good consumer practice for most purchases, but it’s especially important when choosing health insurance. (Valeriya/Getty)

Doing your research is a good consumer practice for most purchases, but it’s especially important when choosing health insurance.

If you buy a lemon of a car or a faulty TV, there are consumer protections in place—such as warranties or safety standards. But when it comes to something as important as your health insurance, you might be surprised by the fine print. Unfortunately, too few patients understand that insurance practices can leave them stuck footing the bill for vital medical care.

As millions of Americans consider their options during Medicare’s open enrollment season, which runs through Dec. 7, it is critical for consumers to pay close attention to insurance restrictions that can delay, disrupt, and deny treatments recommended by their doctors.

One such restriction is called prior authorization (sometimes referred to as pre-authorization or pre-certification). Under prior authorization, insurance company representatives must review and approve a doctor-prescribed treatment or service before it will be covered.

While originally developed to manage the cost of expensive or experimental procedures, prior authorization too often leads to frustrating care delays and denials for necessary medical care.

Case in point: Aetna, one of the country’s largest and most profitable insurers, imposed a new prior authorization requirement this summer for all cataract surgeries, across all of its plans and regardless of patient health status. In just the first month that the policy went into effect, tens of thousands of patients had their sight-restoring surgeries canceled—some of whom are still waiting for approval despite the fact that cataracts disrupt everyday activities, make it harder to drive or work safely, and increase the risk of falls and accidents.

Unfortunately, the number of medical services requiring prior authorization is increasing even as the pandemic continues. Across specialties as vast as oncologyrheumatology and psychiatry (just to name a few), the abuse of this cost-saving practice is getting worse.

In fact, more than 4 in 5 medical groups reported an increase in prior authorization requirements since 2020, and 94% of physicians said that prior authorization delayed medically necessary care for patients. Sadly, a 2020 American Medical Association survey shows 30% of physicians reporting serious adverse events amongst patients who had their treatments disrupted by insurers’ prior authorization policies. Clearly, this is a growing trend that must be addressed.

Luckily, Congress is currently working on a fix to protect patients from prior authorization oversteps. The Improving Seniors’ Timely Access to Care Act of 2021 is bipartisan legislation that would streamline the prior authorization approval process, put safeguards around this sometimes abusive practice, and modernize Medicare Advantage. This legislation is gaining steam in Washington: with over 245 bipartisan cosponsors, the bill enjoys a commanding majority in the House and is quickly accumulating support in the Senate since it was introduced in late October.

In the meantime, consumers must carefully consider their options.

Some plans might look attractive on the surface, but a deeper dive may reveal troubling policies such as prior authorization. As such, consumers are encouraged to do their due diligence. Recognizing that shopping for a health plan can be complex and overwhelming, a good starting point is to:

  • Carefully read the brochures or materials each insurance company provides to see what limitations there may be for procedures you care about.
  • Google "[Insurance company name]” alongside “prior authorization” to see what policies they may have in place.
  • Visit the websites of professional medical societies to see what they are saying about each insurer. You might be surprised how well (or not so well) certain insurers adhere to clinical guidelines.
  • When in doubt, ask! Insurance companies should be transparent about what types of care they require prior authorization for—and how often it delays and disrupts physician-recommended treatments.
  • Understand how you can work with providers when it comes to procedures that may require prior authorization.

By doing your due diligence this open enrollment period, you just might avoid getting locked into a plan that won’t meet your unique needs.

Terry Wilcox is the executive director of Patients Rising.