When Paula Chestnut needed a hip replacement last year, a pre-op x-ray revealed an abnormality in her chest.
Chestnut, a 40-year smoker, had an increased risk of lung cancer. MRIs are high-resolution images that can help detect disease.
But her MRI appointments kept getting canceled, Chestnut’s son, Jaron Lu, told KHN. Second, the provider was not available. According to Roux, her ultimate obstacle she faced was that Chestnut’s health insurance company decided her MRI was medically unnecessary and would not allow a visit.
“At least four or five times she called me hysterically,” Roux said.
A few months later, Chestnut was rushed to the emergency room with shortness of breath. Her breast tumor had grown so large that it was compressing her windpipe. Her doctors started chemotherapy, but it was too late. Despite her treatment, she died in hospital within 6 weeks of admission.
Roux doesn’t entirely blame the health insurance company for his mother’s death, but “it played a part,” he said. “It limited her options.”
Few things about the U.S. healthcare system infuriate patients and doctors more than pre-approval, a common tool whose use by insurers has exploded in recent years.
Preapproval or prequalification was designed decades ago to prevent doctors from ordering unnecessary and expensive tests and procedures with the aim of providing cost-effective care.
While insurers initially focused on the most expensive types of care, such as cancer treatments, they now offer advance coverage for many mundane medical procedures, such as basic imaging tests and prescription refills. Asking for approval has become commonplace.of 2021 survey According to a survey conducted by the American Medical Association, 40% of physicians say they have pre-approved, dedicated staff.
So instead of providing a guardrail against useless and costly treatments today, pre-approval prevents patients from getting the critical care they need, say researchers and doctors.
“The pre-certification system for clinics should be completely abolished.” Dr. Shika Jain, Chicago hematologist-oncologist. “These unnecessary delays are truly devastating.”
In December, the federal government suggested some changes This will force health care plans, including Medicaid, Medicare Advantage, and Federal Affordable Care Act marketplace plans, to expedite pre-approval decisions and provide more information about reasons for denial. . Starting in 2026, for standard pre-approval requests he will normally have 7 days instead of 14 as he currently does, and for urgent requests he will need to plan to respond within 72 hours. The proposed rule is Solicit public comments Until March 13th.
Groups such as AHIP (a trade group formerly known as America’s Health Insurance Plans) and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes. Some doctors feel they are not that advanced. sufficient.
“Seven days is still too long,” he said Dr. Julie CantorA hematologist in Birmingham, Alabama, when a patient with sickle cell disease arrives at the hospital showing signs of a stroke, treatment cannot be delayed. must be put down.”
Meanwhile, some states have passed their own laws governing the process. For example, in Oregon, health insurance companies must accommodate non-urgent advance approval requests. Within 2 business daysIn Michigan, insurance companies Report annual preapproval data, including the number of rejected requests and the number of appeals received.adopted or adopted by other states Similar legislation under considerationin many places, insurers routinely take four to six weeks for non-urgent appeals.
Various studies have shown that waiting for health insurance companies to approve treatments has consequences for patients.it led to delay in cancer treatment In Pennsylvania, it means sick children of colorado likely to be hospitalized and blocked low-income patients nationwide From being treated for opioid addiction.
In some cases, care is denied and never obtained. In other patients, prior approval proved to be a strong but indirect deterrent. Because few patients have the courage, time, or resources to navigate what can be a maze-like process of denial and complaint. Fighting refusals often required patients to submit multiple forms over the phone or on a computer for hours, so they simply gave up.
Erin Conrisk, a social science researcher at the University of California, Riverside, last summer spent dozens to get pre-approved to take a six-mile round trip ambulance ride to take her mother to a clinic in San Diego. I’m assuming you spent some time on it.
Her 81-year-old mother has rheumatoid arthritis and has had difficulty standing, walking and standing after damaging a tendon in her pelvis last year.
Conrisk thought her mother’s case was clear, especially since she had successfully scheduled an ambulance trip to the same clinic a few weeks earlier. I didn’t show up that day. No one informed us that the ride was not pre-approved.
The time it takes to process advance approval requests can perpetuate racial disparities and disproportionately affect those in low-paid, hourly jobs, he said. Dr. Kathleen McManusa medical scientist at the University of Virginia.
“When people ask for examples of structural racism in medicine, this is what I give them,” McManus said. “It’s built into the system.”
McManus’ research Published in 2020, her colleagues found that Federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require pre-approval for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown.but she said so more than half of the nation’s black population If they live in the South, they will be more likely patients to face this barrier.
Many denied claims are reversed if the patient appeals. federal governmentNew data specific to Medicare Advantage plans found that 82% of appeals resulted in a full or partial overturn of the initial preapproval denial. According to KFF.
Patients are not the only ones who are confused and frustrated by this process. Physicians say they find the system complex and time-consuming, and feel like their expertise is being tested.
Mr Kanter, a Birmingham haematologist, said, “I’m wasting my time arguing … with people who really don’t know what I’m talking about.” We are rarely in the medical field.”
In some cases, sending a patient to the emergency room is more efficient than negotiating with an insurance plan to pre-approve images and tests. It costs.
“It’s a terrible system,” she said.
a KFF Analysis of Claims Data for 2021 found that 9% of all denials in its network from the Federal Stock Exchange, healthcare.gov’s Affordable Care Act plans were due to a lack of prior approval or referral, although some companies are more likely to deny a claim for these reasons than for any other reason. For example, in Texas, analysis found that 22% of all denials by Blue Cross and Blue Shield of Texas and 24% of all denials by Celtic Insurance Co. were based on lack of pre-approval.
In the face of scrutiny, some insurers are revising their previous approval policies. UnitedHealthcare has cut the number of advance clearances in half in recent years by eliminating the need for patients to obtain clearance for some diagnostic procedures, such as her MRI and her CT scan, a company spokesperson said. Heather Soules said.Adopted by health insurance companies artificial intelligence technology Speed up earlier approval decisions.
On the other hand, most patients don’t have the means to circumvent the cumbersome process that has become a defining feature of American healthcare. They may not get the results they want.
When an ambulance didn’t arrive in July, Conlisk and her mother’s caregiver decided to take the patient to the clinic in the caregiver’s car.
“She nearly fell outside the office,” Conrisk said. Conrisk needed the help of her five bystanders to move her mother safely to the clinic.
When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day for two weeks leading up to the clinic visit, and worked to get advance clearance. rice field. Her efforts were unsuccessful. Again, her mother’s caregiver took her to the clinic herself.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. KHN is one of his three major operational programs in the United States, along with policy analysis and polling KFFMore (Kaiser Family Foundation). KFF is a donated non-profit organization that provides information on health issues to the public.
