US lawmakers eye health insurance reform as frustrations mount

In the wake of the killing of Brian Thompson, the CEO of UnitedHealthcare,
and the outpouring of frustration about insurance coverage,
#prior #authorizations have emerged as a particular roadblock in healthcare.

Prior authorization requires medical providers to get an insurer’s approval before patients receive healthcare or medications.
💥“As a physician, prior authorization is the number one frustrating thing of practicing outpatient medicine right now, far and away,”
said Dr Gabriel Bosslet, a pulmonologist and professor at Indiana University School of Medicine.

⚠️“I spend more time trying to figure out how I need to get this medication approved than I do seeing the patient and making a diagnosis and writing the prescription.”

Originally intended to control the costs of certain medications and treatments, the frequency of prior authorization requirements has risen in recent years
-- and they now plague common and inexpensive care.

https://www.theguardian.com/us-news/2024/dec/31/health-insurance-prior-authorization?CMP=Share_iOSApp_Other

If a plan has disputes solved by external entities on an increased basis, this can lead to them losing star ratings - this will lead to a drop in revenue indirectly (if marketplace or private via loss of sales) or directly (if Medicaid or Medicare, via loss of state funds)

Plans will try to avoid external complaints for that reason.

#healthinsurance #denials #claims #authorizations

Plans usually have the following dispute process

Internal appeal (the plan reviews)
External appeal (third party reviews)
Fair hearing (state reviews)

Then there is complaints
First internally, than with the state (insurance commision, attorney general, so on)

You usually can’t file complaints until plans’ contractual process is exhausted

#healthinsurance #claims #authorizations #denials

Regrettably, I work for a health insurer. I’m in CS, so I’m not involved in denial, but it has been morally injurious (I’ve been looking elsewhere for sometime, I suck at interviews lol).

If facing denials - follow the plans procedures - this may seem bad faith, but may prevent you from doing other actions.

#healthinsurance #denials #claims #authorizations #healthcare

“Not Medically Necessary”:

Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care

Every day, patients across America crack open envelopes with bad news.
Yet another health insurer has decided not to pay for a treatment that their doctor has recommended.
But the insurance companies don’t always make these decisions.
Instead, they often outsource medical reviews to a largely hidden industry
that makes money by turning down doctors’ requests for payments, known as #prior #authorizations.
Call it the denials for dollars business.

The biggest player is a company called #EviCore by #Evernorth, which is hired by major American insurance companies
and provides coverage to 100 million consumers
— about 1 in 3 insured people.
It is owned by the insurance giant #Cigna.

A ProPublica and Capitol Forum investigation found that
EviCore uses an algorithm backed by artificial intelligence,
which some insiders call “the dial,”
that it can adjust to lead to higher denials.

Some contracts ensure the company makes more money the more it cuts health spending.
And it issues medical guidelines that doctors have said delay and deny care for patients.

EviCore and companies like it approve prior authorizations
“based on the decision that is more profitable for them,” said Barbara McAneny, a former president of the American Medical Association and a practicing oncologist.
“They love to deny things"

https://www.propublica.org/article/evicore-health-insurance-denials-cigna-unitedhealthcare-aetna-prior-authorizations