For decades, Amina Thorin battled mysterious and debilitating pain that spread throughout her body. Several years ago, when her doctor finally diagnosed her with polyneuropathy, a chronic neurological disease, she began using her wheelchair.
Doctors prescribed blood transfusion therapy, and Thorin, 40, was able to live a normal life. That is, until about three months ago, when it came time for reauthorization, Medicaid stopped paying for the treatment. This was the result of a process called pre-approval, which is becoming increasingly common between private and public insurers.
Monthly IV fluids for Thorin’s symptoms cost about $18,000 each. When Medicaid stopped covering IVs, she simply stopped receiving them.
“The doctor showed me why I needed it, and they just decided I didn’t need it,” Tolin, who lives in Tucson, Arizona, told Stateline. “It’s terrible. I’m suffering.”
To reduce health care costs and block unnecessary services, insurance companies have long been required to get a doctor’s approval before paying for certain drugs, treatments, and procedures. But in recent years, many doctors and patients say insurance companies have accelerated their use of prior authorizations, causing delays or denials of treatment that can cause harm or even death. .
In recent years, 20+ states States are considering legislation to minimize delays or denials of prior authorization, and nine states have enacted new laws, according to the American Medical Association, which supports the legislation.
a new jersey lawFor example, most claims have a 72-hour deadline.created by texas “Gold Card” system Physicians with a 90% approval rate will be exempt from prior approval requirements. State of Washington while requiring insurers to automate processes to set deadlines and speed approvals; michigan mandate Prior authorization requirements are based on peer-reviewed standards.
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“It’s really just a matter of building momentum and continuing this situation in more states,” said Dr. Jack Resneck, who resigned as president of the American Medical Association last June.Many of the bills are aimed at organizations. model legislation.
“I hope that insurance companies realize that this is a complete overreach and that it is harming patients and preventing people from receiving appropriate, evidence-based care,” Resneck told Stateline. I hope they recognize it.”
Insurers argue that prior authorization ensures that doctors prescribe only medically necessary treatments, protecting patients and lowering health care costs for everyone. Prior authorization “is intended to ensure that clinical care is consistent with evidence-based recommendations and does not deny or prevent patients from receiving the care they need.” said Robert Traynham, a spokesman for AHIP, the industry group formerly known as America’s Health Insurance Plans. I wrote in an email.
Meanwhile, some supporters of curbing prior approvals warn that the new state law may not make much of a difference, largely because it lacks strong enforcement mechanisms.
Don’t kid yourself that patients will never have to deal with false refusals. Don’t kid yourself that patients will never have to deal with false refusals. Don’t kid yourself that patients will never have to deal with false refusals.
– Ron Howrigon, former executive at insurance giant Cigna
Ron Howligon, a former executive at insurance giant Cigna and current president of Fulcrum Strategies, which specializes in insurance contracts, said the law is “better than nothing” and “definitely will help some people.” There is,” he said. [they’re] I’ll go help you. ”
But Hauligon said insurers are adept at finding ways to circumvent liability laws, especially when the only enforcement against them is third-party reviews and relatively small fines. Stated.
“Let’s not kid ourselves that patients will never have to deal with false denials,” Hauligon told Stateline. “Because that’s not right.”
Additionally, state laws generally apply to state-regulated private health insurance plans. 65% of people These are people who work for large companies and are covered by self-funded employer plans. Additionally, many state laws do not apply to people on Medicaid, the joint state and federal health care program for low-income people, according to the National Association of Insurance Commissioners.
Earlier this year, the federal Centers for Medicare and Medicaid Services completed the rules It is intended to expedite pre-approval in government insurance programs, including Medicaid and Medicare (federal health insurance programs for people 65 and older and people with disabilities). Most of the new rules are expected to take effect in 2026, and require decisions on “urgent” requests to be made within 72 hours. However, it only applies to “medical goods and services” and not to pharmaceuticals.
‘fed up’
Dr. Amy Faith Ho, an emergency physician in Dallas, said many patients whose treatment is delayed or denied prior authorization often end up spending time in waiting rooms.
“At some point, they get fed up. But what’s sad to me is that they did everything right,” Ho said. She added that some patients with chronic illnesses do not end up in the emergency room, but experience a decreased quality of life. “We sometimes see these patients attempt suicide,” she says.
Delays or denials of prior authorization are common for patients with certain diseases and conditions, such as cancer: A 2023 study It was found that one in five cancer patients do not receive the care recommended by their treatment team because of the prior authorization process.in 2022 survey In a survey conducted by the American Medical Association, 94% of physicians said prior authorization led to delays in treatment, and one-third said prior authorization resulted in “serious adverse events” for patients being treated. reported.
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Kay Pestaina, director of the patient and consumer protection program at KFF, a nonprofit research organization, said countries generally try to attack the problem in four ways.
The first strategy is to reduce the amount of time it takes for insurers to decide on drug or service requests.
Second, it often reduces the administrative burden experienced by physicians by giving a pass to those with higher approval ratings. Texas’ Gold Card system is one example.
A third approach is to strengthen transparency and data requirements.
And fourth, it focuses on the review process itself by requiring decisions to be made based on peer-reviewed clinical data.
Pestaina said it may take years to determine which strategy, or combination of strategies, will produce the best results.
In Texas, for example, the 2022 Gold Card Act has had mixed results so far. Doctors who have received passes say there is a more streamlined process, but there aren’t many of them. By the end of last year, only 3% of doctors had achieved gold card status. According to the Texas Medical Association.
“It really should be flipped and go in the opposite direction,” said Resneck, a former president of the American Medical Association. “Instead of 97% of doctors not getting a gold card, 97% should get a gold card.”
Enforcement challenges
The state insurance commissioner will be primarily responsible for enforcing state law. Many of the new laws give commissioners the power to investigate insurance companies, fine them for violations, and even sue them and strip them of their license to operate in the state.
But commissioners will rely heavily on complaints from patients and doctors to detect violations, according to the National Association of Insurance Commissioners. And Haurigon points out that doctors and patients must be aware of their rights under the new law to file a complaint.
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Haurigon also stressed that state-issued fines and fines may not be enough to bring down insurance giants that make tens of billions of dollars in profits. And in 11 states, insurance commissioners are elected and often receive campaign contributions from the companies they regulate, he noted.
He suggested that a better enforcement approach would be to hold medical directors within insurance companies accountable for decisions that harm patients.
“If these doctors had the same accountability and responsibility as the doctors who are writing the prescriptions, meaning they could be sued for medical malpractice… all of this would stop,” Haurigon said. Told.
Based on the prior authorization bill, oklahomaThe insurance company’s medical director may be held liable for medical malpractice and may be sued.
“Doctors have told me this is some of the best legislation they’ve seen in this country. It’s fair to insurance companies and it’s fair to patients.” said Congressman Ross Ford. “This not only provides the appropriate balance of oversight, but is also sufficient to hold insurers accountable if they choose to refuse the procedure.”
3 months at a loss
In Arizona, a bill has been submitted This means that even if a patient changes insurance companies, the insurance company must honor the prior authorization for at least 90 days. But this does not apply to Medicaid, according to the Arizona Department of Insurance.
In other words, this does not apply to Amina Thorin.
Medicaid finally approved Thorin’s IV in late March. But during her three months at a loss, she says her symptoms, including pain, fatigue, numbness and tingling, were distressing.
She is concerned that at some point in the future, Arizona Medicaid may once again deny coverage for the infusion, which will be covered for the next 12 months.
“I feel like I won, but in reality I didn’t, because a year later it’s a whole new battle,” she said.
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