A major pain point for physicians is also one—sometimes literally—for patients.
In Texas, 25% of patients say insurers have refused to cover a medicine, procedure, test or scan that a doctor ordered for them or a family member, according to a statewide survey conducted by the Texas Medical Association, the largest state medical society in the country.
Some 16% of respondents say they got sicker as a result of the insurer’s denial.
Prior authorization is a major headache for physician practices, and a Medical Group Management Association survey last year found practice leaders ranked it the most burdensome regulatory issue they face.
It’s also a painful issue for patients. One in 4 voters answered “yes” when asked whether they or a family member experienced an insurer’s denial from a private insurer, Medicare or Medicaid in the past year. The Texas Medical Association authorized the telephone survey, which asked 800 registered voters in Texas about insurance company practices on Jan. 12-14.
“Insurers are supposed to finance needed care, not prevent it,” said David Fleeger, M.D., president of the medical association, in an announcement about the survey. “These big companies are reporting record profits, and our patients are paying for it with their wallets and their health.”
Of those whose doctors’ orders were denied, 10% said they or their family member “got a lot sicker” or a diagnosis was “extremely delayed,” and 6% said they got “somewhat sicker” or their diagnosis was “somewhat delayed,” the survey found.
In a survey last year by the American Medical Association, 28% of physicians said prior authorization led to serious adverse events for patients.
Denials by insurers can be costly for patients, as 30% said they paid for the medicine, procedure, test or scan themselves. Another 14% said they appealed the denial and the insurance company changed its decision.
Some 24% of respondents said they never got the medicine, procedure or test, but nothing bad happened as a result.
“Physicians already know how much time and energy we spend fighting insurance companies on our patients’ behalf,” Fleeger said. “We already know how much our patients suffer when care is delayed or denied. These survey results document just how widespread and harmful the problem is.”
In the 2019 session of the Texas Legislature, the Texas Medical Association said it won reforms that force insurance companies to be more open about what doctors’ orders they review and how that review process works. The new law also requires that the companies’ reviewers work under the direction of a physician licensed to practice medicine in Texas.
Along with other physician groups, the Texas association hopes for further changes on the state and national levels including requiring health plans to eliminate prior authorization requirements for services, medical equipment and medications that are routinely approved.
It also hopes to require plans to streamline or automate the prior authorization process to reduce on-hold and waiting times.
In separate recent surveys, 84% of providers reported the number of medical services that require prior authorization has increased, as well as the cost for physician practices, which also continued to increase—up 60% in 2019 to manually generate a request to insurers.
And 62% of providers reported they do not have the technology to evaluate whether a prior authorization is required for a medical service, diagnostic test or medication without initiating a prior authorization request, according to a survey by the nonprofit WEDI.