Insurance pre-authorization requirements can lead to “devastating” delays

When Paula Chestnut needed hip replacement surgery last year, a pre-op X-ray revealed abnormalities in her chest.

As a smoker for 40 years, Kesten was at high risk of lung cancer. A specialist in Los Angeles recommended that the 67-year-old undergo an MRI, a high-resolution image that can help detect the disease.

But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. The supplier was then unavailable. The final hurdle she faced, Roux said, came when Chestnut’s health insurer deemed the MRI medically unnecessary and wouldn’t authorize the visit.

“At least four or five times she called me in hysterics,” Roux said.

Months later, Chestnut, struggling to breathe, was rushed to the emergency room. The tumor in her chest had grown so large that it was pressing on her trachea. Doctors started chemotherapy, but it was too late. Despite treatment, she died in hospital within six weeks of admission.

While Roux doesn’t entirely blame the health insurance company for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

Few things about the American health care system infuriate patients and doctors more than the advance authorization, a common tool whose use by insurers has exploded in recent years.

Prior authorization, or prior certification, was created decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or necessary in order to provide cost-effective care.

Originally focused on the most expensive types of care, such as cancer treatment, insurers now typically require prior authorization for many routine medical exams, including basic imaging tests and prescription fillings. In a 2021 survey conducted by the American Medical Association, 40 percent of physicians said they had employees who worked exclusively with prior authorization.

So today, instead of providing a guardrail against useless, expensive treatment, prior authorization prevents patients from getting the vital care they need, researchers and doctors say.

“The prior authorization system should be completely eliminated in doctors’ offices,” said Dr. Shikha Jain, a hematologist-oncologist in Chicago. “It’s really devastating, these unnecessary delays.”

In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage and the Affordable Care Act’s federal marketplace plans, to speed up pre-authorization decisions and provide more information about reasons for denials. Starting in 2026, it will require plans to respond to a standard prior authorization request within seven days, usually instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment until March 13.

Although groups such as AHIP, an industry trade group formerly known as American Health Insurance Plans, and the American Medical Association, which represents more than 250,000 doctors in the United States, have expressed support for the proposed changes, some doctors believe they do not go far enough. far enough.

“Seven days is still too long,” said Dr. Julie Kanter, a hematologist in Birmingham, Ala., whose sickle-cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “We have to act very quickly. We have to make decisions.”

Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to non-urgent prior authorization requests within two business days. In Michigan, insurers must report annual prior authorization data, including the number of claims denied and appeals received. Other states have passed or are considering similar legislation, while in many places insurers routinely take four to six weeks for non-urgent appeals.

Waiting for health insurers to authorize care has consequences for patients, various studies show. That led to delays in cancer care in Pennsylvania, which meant sick children in Colorado were more likely to be hospitalized and blocked low-income patients across the state from getting treatment for opiate addiction.

In some cases, care was denied and never received. In other cases, prior authorization has proven to be a powerful but indirect deterrent because few patients have the fortitude, time or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up because fighting denials often required patients to spend hours on the phone and computer to submit multiple forms.

Erin Konlisk, a social science researcher at the University of California-Riverside, estimated that she spent dozens of hours last summer trying to get pre-authorization for a 6-mile round-trip ambulance ride to take her mother to a clinic in San Diego.

Her 81-year-old mother has rheumatoid arthritis and had trouble sitting, walking or standing unaided after damaging a tendon in her pelvis last year.

Conlisk thought her mother’s case was clear, especially since they had successfully scheduled an ambulance transport several weeks earlier to the same clinic. But the ambulance didn’t turn up the day Conlisk was told. No one informed them that the trip was not pre-authorized.

The time it takes to process a prior authorization request can also perpetuate racial disparities and disproportionately affect people in lower-paying hourly jobs, said Dr. Kathleen McManus, a physician-scientist at the University of Virginia.

“When people ask for an example of structural racism in medicine, I give them this,” McManus said. “It’s logged in the system.”

Research published by McManus and her colleagues in 2020 found that federal insurance plans in the Affordable Care Act marketplace in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional differences is unknown. But she said that since more than half the nation’s black population lives in the South, they would be the patients most likely to face that barrier.

Many of the denied claims are overturned if a patient appeals, according to the federal government. New data specific to Medicare Advantage plans found that 82 percent of appeals resulted in full or partial reversal of the original denial of prior authorization, according to KFF.

It’s not just patients who are confused and frustrated by the process. Doctors said they found the system complicated and time-consuming and felt as though their expertise was being challenged.

“I waste hours of time that I really shouldn’t have to argue … with someone who doesn’t even know what I’m talking about,” said Canter, the Birmingham hematologist. “The people who make these decisions are rarely in your field of medicine.”

Sometimes, she said, it’s more efficient to send patients to the emergency room than to negotiate with their insurance plan for prior authorization for imaging or tests. But urgent care costs more to both the insurer and the patient.

“It’s a terrible system,” she said.

A KFF analysis of 2021 claims data found that 9 percent of all denials on the federal exchange’s Affordable Care Act plan network, healthcare.gov, were due to a lack of prior authorization or referrals, but some companies are more likely to deny claims for these reasons than others. In Texas, for example, the analysis found that 22 percent of all denials made by Blue Cross and Blue Shield of Texas and 24 percent of all denials made by Celtic Insurance Co. were based on a lack of prior authorization.

Faced with scrutiny, some insurers are revising their pre-authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years, eliminating the need for patients to obtain authorization for some diagnostic procedures, such as MRIs and CT scans, company spokeswoman Heather Soules said. Health insurers have also adopted AI technology to speed up prior authorization decisions.

Meanwhile, most patients have no way to avoid the arduous process that has become a defining feature of American health care. But even those who have the time and energy to fight back may not get the result they were hoping for.

When the ambulance never showed up in July, Konlisk and her mother’s caregiver decided to drive the patient to the clinic in the caregiver’s car.

“She almost fell out of the office,” said Conlisk, who needed the help of five bystanders to move his mother safely into the clinic.

When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend just one hour a day, for two weeks leading up to the clinic visit, working to get a pre-authorization. Her efforts were unsuccessful. Once again, her mother’s caregiver drove her to the clinic alone.