You’re denied care, and your doctor is burned out. Why? Prior authorizations and claim denials. Let’s tackle prior authorizations first.
This post is a part of our 30 Days of US Healthcare series. You can watch all the videos in this series on YouTube and learn more about the content behind the videos here on our blog.
BY THE NUMBERS
In a 2022 American Medical Association1 survey of physicians’ experiences with prior authorizations:
🩺 94% reported care delays due to prior authorizations
🩺 89% reported a negative impact on patient outcomes
🩺 88% reported prior authorizations are a high, or extremely high, burden
WHAT’S GOING ON WITH PRIOR AUTHORIZATIONS?
A prior authorization is when your healthcare provider must submit a request to your insurance company for medically necessary care before you can receive it with insurance coverage.
Initially, US insurance companies used prior authorizations for expensive procedures and prescriptions to ensure medical necessity and the exploration of less expensive alternatives meeting the standard of care.2
THE STATED GOAL? KEEPING DOWN HEALTHCARE COSTS.
Now, prior authorizations are used for various common treatments and procedures, including generic drugs.
On average, US doctors submit 45 prior authorizations a week. Completing the tasks around these authorizations takes 2 full business days a week for doctors and their staff. Nearly 2 out of 5 doctors have full-time staff dedicated to working on prior authorizations.1
“In 2021, data from 515 Medicare Advantage contracts, representing 23 million Medicare Advantage enrollees (87% of Medicare Advantage enrollment), included 35.2 million prior authorization determinations”.4
We don’t have data for the US as a whole because the federal government doesn’t require reporting of this data. This means that the data that exist are messy, inconsistent, and incomplete.
There are instances where people with Type 1 Diabetes must get a prior authorization every 3 months to refill supplies for their insulin pump. The process sometimes takes so long that they run out of supplies before receiving approval. Approval that, in this case, is a forgone conclusion.3
In fact, 34% of doctors report that prior authorizations have led to a “serious adverse event (e.g., death, hospitalization, disability/permanent bodily damage, or other life-threatening event)” for one of their patients.
Here’s what’s especially shocking, the people denying your preauthorizations aren’t doctors. Yet, they are the ones determining if your doctor’s proposed care is evidence-based.5
CLEARLY, THE GOAL IS TO INCREASE INSURANCE COMPANIES’ PROFITS.
WHAT CAN I DO IF MY PRIOR AUTHORIZATION IS DENIED?
Work with your healthcare provider to appeal.
Remember the 23 million Medicare Advantage patients for whom we have data? Only 11% of their denied prior authorizations were appealed. This is exactly what the insurance companies are counting on.
HERE’S WHAT THEY DON’T WANT YOU TO KNOW.
APPEALS WORK
More than 80% of Medicare Advantage patients’ appeals resulted in the denial being overturned. The appeal process can be brutal, and it’s not a sure thing, and it doesn’t fix the systemic problem. But it can work.
GO DEEPER
Learn why we don’t have data that allows us to select insurance companies based on their rates of denial.
Check out the results of the American Medical Association’s physician survey on prior authorizations.
See what doctors wish their patients knew about prior authorizations.
Share your prior authorization story of delayed or denied care with the American Medical Association to help them draw attention to the issues surrounding prior authorizations.
1 AMA Prior Authorization (PA) Physician Survey | AMA, www.ama-assn.org/system/files/prior-authorization-survey.pdf.
2 Sara Berg. “What Doctors Wish Patients Knew about Prior Authorization.” American Medical Association, 29 July 2022, www.ama-assn.org/practice-management/prior-authorization/what-doctors-wish-patients-knew-about-prior-authorization.
3 Andrews, Michelle. “Why so Slow? Legislators Take on Insurers’ Delays in Approving Prescribed Treatments.” KFF Health News, 17 May 2022, kffhealthnews.org/news/article/prior-authorization-treatment-insurers-doctors-faster.
4 Jeannie Fuglesten Biniek and Nolan Sroczynski. “Over 35 Million Prior Authorization Requests Were Submitted to Medicare Advantage Plans in 2021.” KFF, 3 Feb. 2023, www.kff.org/medicare/issue-brief/over-35-million-prior-authorization-requests-were-submitted-to-medicare-advantage-plans-in-2021/.
