Health insurers promise to improve coverage reviews that prompt delays and complaints
The nation's major health insurers are promising to scale back and improve a widely despised practice that leads to care delays and complications.
UnitedHealthcare, CVS Health's Aetna and dozens of other insurers said Monday that they plan to reduce the scope of health care claims subject to prior authorization, standardize the process and expand the number of responses done in real time.
Prior authorization means insurers require approval before they'll cover medical care, a prescription or a service like an imaging exam. Insurers say they do this to guard against care overuse and to make sure patients get the right treatment.
But doctors say the practice has grown in scope and complication, leading to frequent care delays. The fatal shooting of UnitedHealthcare CEO Brian Thompson in December prompted many people to vent their frustrations with coverage issues like prior authorization.
Dr. Mehmet Oz called prior the practice 'a pox on the system' that hikes administrative costs during his Senate confirmation hearing in March to lead the Centers for Medicare and Medicaid Services.
Insurers said Monday that they will standardize electronic prior authorization by the end of next year to help speed up the process. They will reduce the scope of claims subject to it.
They also plan to expand the number of real-time responses and ensure medical reviews are done for denied requests.
Researchers say prior authorization has grown more common as care costs have climbed, especially for prescription drugs, lab testing, physical therapy and imaging exams.
'We're sort of trapped between care being unaffordable and then these non-financial barriers and administrative burdens growing worse,' said Michael Anne Kyle, an assistant professor at the University of Pennsylvania who studies how patients access care.
Nearly all customers of Medicare Advantage plans, the privately run version of the federal government's Medicare program, need prior authorization for some services, particularly expensive care like hospital stays, the health policy research organization KFF found in a study of 2023 claims. The study also found that insurers denied about 6% of all requests.
Dr. Ashley Sumrall of Charlotte, North Carolina, says she has seen an increase in prior authorizations required for routine exams like MRIs. An oncologist who treats brain tumors, Sumrall said these images are critical for doctors to determine whether a treatment is working and to plan next steps.
Doctors say delays from requests that are eventually approved or coverage rejections can harm patients by giving a disease time to progress untreated. They also can spike anxiety in patients who want to know whether their tumor has stopped growing and if insurance will cover the scan.
'There's a term that we use called 'scanxiety,' and it's very real,' said Sumrall, a member of the Association for Clinical Oncology's volunteer leadership.
Different forms and varied prior authorization policies also complicate the process. Sumrall noted that every insurer 'has their own way of doing business.'
'For years, the companies have been unwilling to compromise, so I think any step in the direction of standardization is encouraging,' she said.
___
The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute's Science and Educational Media Group and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Daily Mail
an hour ago
- Daily Mail
Unfathomable moment America's top health official indulges in cancer-causing act
Robert F Kennedy Junior is no stranger to a wellness routine, but his latest one is raising eyebrows as critics point out the health secretary's hobby could cause cancer. RFK Jr, 71, was snapped leaving a tanning salon in Washington, DC last week surrounded by a team of security guards. In the clip, he is shown exiting Palm Beach Tan, a business that offers multiple tanning services. The salon says it is '100 percent dedicated to helping you find your perfect shade', offering both UV beds — linked to skin cancer and premature aging — and spray-on tans — which may cause DNA damage. The national chain states it offers 'cutting-edge sunbed and spray tanning options,' as well as 'state-of-the-art wellness services, including red light therapy, infrared saunas, and more'. It isn't known which service the secretary received and when contacted by a receptionist at the salon declined to comment. She told this website: 'We can't comment on that; have a nice day.' However, if the secretary did receive one of the tanning treatments, he could be setting himself up for major health problems, as tanning beds are associated with an up to 75 percent higher risk of skin cancer and chemicals in spray-on tan mists are linked to DNA damage and breathing problems. The Department of Health and Human Services did not respond to a request for comment now has he made any previous comments on his complexion or tanning habits. Tanning beds use high-intensity UV radiation to produce a sun-kissed look, but this radiation can also penetrate the skin and damage the DNA of cells. Experts say there is no safe level of exposure from these beds, while the International Agency for Research on Cancer lists them as Group 1 carcinogens — on the same level as tobacco smoke and asbestos. While spray tans don't use UV, their mist contains an additive called dihydroxyacetone, or DHA, a compound made from sugar that can attach to proteins on the surface of the skin to create a tan. Small amounts of this tan may be able to enter the skin, however. A 2004 lab study found a link between DHA and an increased risk of DNA damage, which could cause cancer - though it didn't list a specific type of the disease. DHA has also been linked to skin irritation and concerns over breathing problems if someone inhales the fumes. RFK Jr's tanning salon visit was revealed in a post on TikTok from Cody Miller, a fitness fanatic in the local area. He posted the Health Secretary to background music from Spongebob Squarepants, and with the comment: 'Nothing like being unhealthy on a Tuesday afternoon'. The clip has since gone viral, racking up more than 1.1million views. One commentator responded, 'and he's worried about red dyes?', while a second said, 'Is it a requirement that they all must be the same shade of orange as Trump?' Another called RFK Jr a 'rotisserie chicken.' People have also responded by dubbing the clip a sign of Make America Orange Again and Make America Tan Again — a nod to the Trump administration's slogan. RFK Jr has not previously commented on his tanning habits but has raised eyebrows over his complexion in the past, especially at his senate confirmation hearing in January — where viewers pointed out he had an orange glow. People on social media were quick to point out the irony that America's top health official was potentially engaging in a cancer-causing act. However, it is not the first case of RFK Jr seemingly skirting his own advice, In another previous case, he was slammed as a 'hypocrite' by doctors after he was snapped with an ultra-processed energy drink that contained potentially toxic ingredients. RFK Jr, who has said he 'never eats' ultra-processed foods, was photographed clutching a bottle of C4 Energy drink at Gold's Gym on Venice Beach in February, while posing for a photo with a former jiu-jitsu world champion. The drink has 17 ingredients in it, including several preservatives that have been linked to major health conditions such as cancer.
Daily Mail
an hour ago
- Daily Mail
Revealed: The stunning new Mounjaro and Ozempic side-effect that could benefit thousands of chronically ill people
They have already taken the weight-loss sector by storm – now the blockbuster drugs Ozempic and Mounjaro could do the same for lymphoedema, a lifelong, progressive swelling disorder that often follows cancer treatment. An estimated 500,000 people in the UK live with the condition, where arms or legs can swell to double their normal size, causing pain and limiting movement, due to a build-up of fluid in the body's tissues.
Daily Mail
an hour ago
- Daily Mail
Experts reveal changes in tongue color and shape could indicate health issues
Scientists have revealed that your tongue could be an important indicator of your health as different colors, textures, coatings and shapes of the tongue can indicate different conditions. Keeping track of the muscular organ could help us detect issues we may otherwise be oblivious to. Sarah Ramage, clinical director at Bupa, said: 'A healthy tongue is pink in color with a slightly rough surface. What gives it this texture are the tiny bumps on top, called papillae.' RED OR WHITE PATCHES Abnormal looking patches, lumps or spots could be a sign of mouth cancer. Red patches could signal a condition called erythroplakia and white or grey patches may be leukoplakia, which could lead to cancer if untreated. Your dentist will look out for these when you go for a check-up, Ramage said, and refer you to a specialist if they have any concerns. 'Mouth cancer rates have increased by almost 60 per cent in the last decade, so it's important to be aware of any changes,' she added. WHITE SPOTS (LESIONS) Creamy white spots or lesions on the tongue could indicate a fungal infection, such as oral thrush. While it's usually harmless it may spread to other parts of your mouth if left untreated, causing an unpleasant taste or pain or difficulty eating and drinking. RED, PURPLE OR PALE Dr Leslie Anthony is a dentist who runs her own practice in Montana. Speaking about what else you should watch out for, she said: 'A red tongue may indicate heat in the body like a fever or a hormonal imbalance. A reddish purple tongue is a sign that there may be inflammation or an infection in the body. 'Meanwhile a pale pink tongue may be a sign of a vitamin deficiency, a weak immune system or a lack of energy.' COATING A thick coating reflects poor intestinal health or digestive issues, Anthony explained. A yellowish coating indicates there may be an infection in the body, while a grey or blackish coating suggests a long-term digestive disorder or that 'something may be very wrong with your body's health'. And a thick white coating means there may be poor circulation to the extremities or possibly a yeast infection. SHAPE 'If the tongue is puffy with scalloped edges or indented teeth marks it may indicate malabsorption of nutrients,' Anthony added. Meanwhile, a very thin tongue may be a sign of dehydration. A BLOTCHY 'GEOGRAPHIC' TONGUE A map-like pattern on the tongue's surface – with normal patches and smooth red patches – occurs when the 'old' surface of the tongue replaces itself and the top layer doesn't come off properly. It can leave a red, sore area like a scratch, but is normally harmless. The experts said it is good practice to look at young tongue in the mirror and notice the colours, textures, bumps and coating. It is best to inspect your tongue before brushing your teeth, they added. HOW TO CLEAN YOUR TONGUE Experts recommend brushing your tongue regularly to help prevent a build-up of bacteria. Tongue brushing is simple enough to do using the bristles of your toothbrush. Colgate's website reads: 'The tongue harbors bacteria and food debris trapped under a thin layer of mucus. Remove this odour-causing build-up by using a small dab of toothpaste and carefully brushing the top of the tongue. 'Start by reaching to the back of the tongue, and then work forwards towards the opening of the mouth. Brush the entire top surface of the tongue using gentle pressure, and then rinse your mouth with mouthwash or water.' For those wanting a more thorough cleaning, a tongue scraper gently peels the thin mucus-based layer of debris from the tongue.
