A new Biden administration rule released Wednesday aims to streamline the prior authorization process used by insurers to approve medical procedures and treatments.
Prior authorization is a common tool used by insurers but much maligned by doctors and patients, who say it’s often used to deny doctor-recommended care.
Under the final rule from the Centers for Medicare and Medicaid Services, health insurers participating in Medicare Advantage, Medicaid or the ObamaCare exchanges will need to respond to expedited prior authorization requests within 72 hours, and standard requests within seven calendar days.
The rule requires all impacted payers to include a specific reason for denying a prior authorization request. They will also be required to publicly report prior authorization metrics.
LPT: If your doctor firmly believes that you require X treatment/medication/etc. Have them use the specific term “medically necessary”. If your insurer kicks it back with that phrasing attached, contact them. Ask for the medical license number of the doctor who indicated that it was not medically necessary. Push for this information (they won’t have it) and continue the line of “Someone on your end is making a medical decision against my doctors orders. I require their credentials so I can confirm they are a) qualified to make medical decisions, and b) have a higher education that my doctor possesses.”
I’ll be interested if someone actually tried this
I speak from experience. Blue Cross has not argued or denied any of our doctors’ requests since the second time I used that method.
Had a specialist tell my wife she needed a shoulder replacement. Insurance wanted her to do physical therapy. I was livid. “I want the license number of the doctor on your end who is deciding that physical therapy is going to some how magically fix torn rotator cuff tendons. Telling our medical specialist that physical therapy is required is a medical decision that contradicts their diagnosis that it needs replaced. If we follow your recommendation and it fails, I need the name and license number of who to go after for making that decision. Shielding this professional, and I use that term loosely, indicates that you’re willing to assume all the liability when “physical therapy” causes more pain and damage.”
Did they ever give you a license number, or did they just cave?
Said they’d have to “look into it”. Called back 20 minutes later to inform that they decided to approve the procedure.
It’s nonsense. For one, what is required for a treatment is handled by CMS and the CPT code itself, so the necessary documentation is either there or it isn’t and adding “medically necessary” doesn’t change a damn thing. Secondly, the commercial payors go by their own schedules for what is always, is never, and can be “medically necessary,” “experimental,” “diagnostic-only,” and a ton more. If your orthopedic surgeon is calling for a prior auth for a total knee replacement, it’s always medically necessary; peripheral vein ablation, it’s sometimes medically necessary; chin implant, never necessary.
Then I’m full of shit and my wife’s reverse shoulder joint is a figment of our collective imaginations.
It’s not one or the other. You’re full of shit and your wife would have gotten her reverse total joint surgery regardless.
Insurers are known to automatically deny procedures based on what is essentially a flow chart (illegal) rather than a medical professional review of the case (required by law). This is why most insurers back down when a prior authorization is requested.
The whole process is being abused by insurers and if you ask doctors, nurses, pharmacists they’ll tell you the process is being abused.
Cigna got caught doing it https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims I guarantee you that most other insurance companies are doing this as well.
Insurance companies are going to do anything they can to reduce loss ratio, but… That is literally the plot of a John Grisham novel (pre-ACA, so it was a little more complicated than that, but still).
Maybe that’s not the model that real-life insurers should be copying.
This reads like a summary of a chapter in a dystopian novel
It reads like sovereign citizen advice.
Ffs, is this truly where we are at? Fuck me…
Nurses usually make these calls, as I understand.