My healthcare is expensive. I get regular scans, treatment every three weeks with two biologic anti-cancer treatments for HER2-positive metastatic breast cancer, care for the various side effects my treatments have caused, expected care from my primary care physicianand all the usual health screenings.
I know firsthand how difficult medical care in the United States can be, how there are gatekeepers at every step from the first call to make an appointment to the difficulty of affording all the care you need — even with insurance—and to insurance itself.
Prior authorization is a key phrase in my own care, and I know people who are denied care, have care delayed, can’t get the correct, most useful scan until after they have a less useful oneand so much more. I hear from clinicians that time spent trying to work around denied care is unpaid, unbillable, excessive, but they continue to fight for their patients to receive the best possible, correct care.
Patients meanwhile also make calls—to the insurer, to the doctor, to support organizations—wasting precious time and energy to fight for the care their own doctors have recommended.
No wonder we are all so tired. Profits are being made, but the people who are bringing those profits (doctors and, unfortunately, patients) are being used and, frankly, abused.
My most recent prior authorization struggle revolved around a second colonoscopy required by my doctor, six months after the previous one. The timing was unusual (and worrisome) for me and a pain logistically. Prior authorization couldn’t be requested until a certain date, but scheduling needed the prior authorization ahead of time. By the time my insurer approved it (success!), it was too late to schedule. I spent hours on the phone trying to find anyone who could get me a workaround for an appointment that came close to 6 months. None of it was right, not for my PCP who had to talk to the insurer, not for me, not for the gastroenterologist.
I finally got the care, at close to the recommended time.But not everyone is as lucky.
The American Society of Clinical Oncology (ASCO) found in a survey of oncologists that “nearly all respondents have experienced patient harm and significant practice hurdles due to prior authorization practices, including delays of treatment (96%); patients forced onto a second-choice therapy (93%); increased patient out-of-pocket costs (88%); denial of therapy (87%); unsuccessful appeals (96%); and lack of transparency in prior authorization process (91%).”
This is an unforgivable, unethical, harmful situation. ASCO also points out that a 2022 U.S. Department of Health and Human Services Inspector General report shows widespread misuse and abuse of prior authorization in Medicare Advantage (MA) plans, harming seniors by delaying or denying important cancer treatments and procedures.
Right now, there are two opportunities to encourage federal legislation and better recommendations. I hope you take the time to do so.
1. Improving Seniors’ Timely Access to Care Act(H.R. 3173/S. 3018) was passed by the House of Representatives on Sept. 14. It is crucial to encourage your Senators to pass this bill before the end of this 2022. Time is running out. This bill aims to streamline prior authorization practices within the Medicare Advantage (MA) program by creating an electronic prior authorization (ePA) process and requiring MA plans to adopt ePA capabilities; requiring HHS to establish a list of items and services eligible for real-time decisions; standardizing and streamlining the prior authorization process for routinely approved items and services; and increasing transparency around MA prior authorization requirements and their use.
You can link to an easy electronic form here.
2. The Centers for Medicare & Medicaid Services (CMS) has proposed new guidelines to improve the prior authorization process (aimed to go into effect on January 1, 2026). These proposals include requiring the regulated payers to include information about patients’ prior authorization decisions to help patients better understand their payer’s prior authorization process and its impact on their care; proposing to require impacted payers to include a specific reason when they deny a prior authorization request, regardless of the method used to send the prior authorization decision, to both facilitate better communication and understanding between the provider and payer and, if necessary, a successful resubmission of the prior authorization request; requiring impacted payers to send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests.
The proposals extend beyond those I listed here. You can read more here and please take the time to provide feedback on the proposals through March 13, 2023 by going to https://www.regulations.gov/commenton/CMS_FRDOC_0001-3462.
This is the time to support better prior authorization methods for yourself or someone you love.
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