Latest news with #priorauthorization
New York Times
8 hours ago
- Health
- New York Times
Insurers Pledge to Ease Controversial Prior Approvals for Medical Care
Facing regulatory crackdowns and intensifying criticism from patients and doctors, the nation's biggest health insurers said on Friday that they would retreat from tactics that have delayed medical care and led at times to denials for necessary treatments. For years, the widespread practice known as prior authorization has vexed patients who might not have been notified until the day of surgery whether a procedure would be covered by their insurance or if a prescription medicine would be denied for no clear reason. Insurers often send unintelligible form letters, leaving patients to puzzle out the basis for the denial or what their next steps should be. Patients may delay or even abandon necessary medical care because they may not even be aware that they can appeal the decisions. Lawmakers, regulators and public outrage have drawn attention to abuses of the system, leading to mounting calls for reforms. Insurers have also been the target of myriad lawsuits, some of which attributed patient deaths to those denials and delays. The murder of Brian Thompson, a UnitedHealthcare executive, last December renewed criticisms of the tactic, unleashing a barrage of complaints that the practice was deployed to avoid covering care. 'Prior authorization is a huge issue for people who are in managed care plans because it is one of the ways plans use to control their costs,' said David A. Lipschutz, co-director for the Center for Medicare Advocacy. He pointed to several studies showing that insurers may have inappropriately denied care, particularly in private Medicare plans. Various reports from federal regulators and researchers show that the vast majority of appeals are successful. Want all of The Times? Subscribe.
Yahoo
16 hours ago
- Health
- Yahoo
How artificial intelligence controls your health insurance coverage
Over the past decade, health insurance companies have increasingly embraced the use of artificial intelligence algorithms. Unlike doctors and hospitals, which use AI to help diagnose and treat patients, health insurers use these algorithms to decide whether to pay for health care treatments and services that are recommended by a given patient's physicians. One of the most common examples is prior authorization, which is when your doctor needs to receive payment approval from your insurance company before providing you care. Many insurers use an algorithm to decide whether the requested care is 'medically necessary' and should be covered. These AI systems also help insurers decide how much care a patient is entitled to — for example, how many days of hospital care a patient can receive after surgery. If an insurer declines to pay for a treatment your doctor recommends, you usually have three options. You can try to appeal the decision, but that process can take a lot of time, money and expert help. Only 1 in 500 claim denials are appealed. You can agree to a different treatment that your insurer will cover. Or you can pay for the recommended treatment yourself, which is often not realistic because of high health care costs. As a legal scholar who studies health law and policy, I'm concerned about how insurance algorithms affect people's health. Like with AI algorithms used by doctors and hospitals, these tools can potentially improve care and reduce costs. Insurers say that AI helps them make quick, safe decisions about what care is necessary and avoids wasteful or harmful treatments. But there's strong evidence that the opposite can be true. These systems are sometimes used to delay or deny care that should be covered, all in the name of saving money. Presumably, companies feed a patient's health care records and other relevant information into health care coverage algorithms and compare that information with current medical standards of care to decide whether to cover the patient's claim. However, insurers have refused to disclose how these algorithms work in making such decisions, so it is impossible to say exactly how they operate in practice. Using AI to review coverage saves insurers time and resources, especially because it means fewer medical professionals are needed to review each case. But the financial benefit to insurers doesn't stop there. If an AI system quickly denies a valid claim, and the patient appeals, that appeal process can take years. If the patient is seriously ill and expected to die soon, the insurance company might save money simply by dragging out the process in the hope that the patient dies before the case is resolved. This creates the disturbing possibility that insurers might use algorithms to withhold care for expensive, long-term or terminal health problems , such as chronic or other debilitating disabilities. One reporter put it bluntly: 'Many older adults who spent their lives paying into Medicare now face amputation or cancer and are forced to either pay for care themselves or go without.' Research supports this concern – patients with chronic illnesses are more likely to be denied coverage and suffer as a result. In addition, Black and Hispanic people and those of other nonwhite ethnicities, as well as people who identify as lesbian, gay, bisexual or transgender, are more likely to experience claims denials. Some evidence also suggests that prior authorization may increase rather than decrease health care system costs. Insurers argue that patients can always pay for any treatment themselves, so they're not really being denied care. But this argument ignores reality. These decisions have serious health consequences, especially when people can't afford the care they need. Unlike medical algorithms, insurance AI tools are largely unregulated. They don't have to go through Food and Drug Administration review, and insurance companies often say their algorithms are trade secrets. That means there's no public information about how these tools make decisions, and there's no outside testing to see whether they're safe, fair or effective. No peer-reviewed studies exist to show how well they actually work in the real world. There does seem to be some momentum for change. The Centers for Medicare & Medicaid Services, or CMS, which is the federal agency in charge of Medicare and Medicaid, recently announced that insurers in Medicare Advantage plans must base decisions on the needs of individual patients – not just on generic criteria. But these rules still let insurers create their own decision-making standards, and they still don't require any outside testing to prove their systems work before using them. Plus, federal rules can only regulate federal public health programs like Medicare. They do not apply to private insurers who do not provide federal health program coverage. Some states, including Colorado, Georgia, Florida, Maine and Texas, have proposed laws to rein in insurance AI. A few have passed new laws, including a 2024 California statute that requires a licensed physician to supervise the use of insurance coverage algorithms. But most state laws suffer from the same weaknesses as the new CMS rule. They leave too much control in the hands of insurers to decide how to define 'medical necessity' and in what contexts to use algorithms for coverage decisions. They also don't require those algorithms to be reviewed by neutral experts before use. And even strong state laws wouldn't be enough, because states generally can't regulate Medicare or insurers that operate outside their borders. In the view of many health law experts, the gap between insurers' actions and patient needs has become so wide that regulating health care coverage algorithms is now imperative. As I argue in an essay to be published in the Indiana Law Journal, the FDA is well positioned to do so. The FDA is staffed with medical experts who have the capability to evaluate insurance algorithms before they are used to make coverage decisions. The agency already reviews many medical AI tools for safety and effectiveness. FDA oversight would also provide a uniform, national regulatory scheme instead of a patchwork of rules across the country. Some people argue that the FDA's power here is limited. For the purposes of FDA regulation, a medical device is defined as an instrument 'intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease.' Because health insurance algorithms are not used to diagnose, treat or prevent disease, Congress may need to amend the definition of a medical device before the FDA can regulate those algorithms. If the FDA's current authority isn't enough to cover insurance algorithms, Congress could change the law to give it that power. Meanwhile, CMS and state governments could require independent testing of these algorithms for safety, accuracy and fairness. That might also push insurers to support a single national standard – like FDA regulation – instead of facing a patchwork of rules across the country. The move toward regulating how health insurers use AI in determining coverage has clearly begun, but it is still awaiting a robust push. Patients' lives are literally on the line. This article is republished from The Conversation, a nonprofit, independent news organization bringing you facts and trustworthy analysis to help you make sense of our complex world. It was written by: Jennifer D. Oliva, Indiana University Read more: Artificial intelligence in medicine raises legal and ethical concerns How can Congress regulate AI? Erect guardrails, ensure accountability and address monopolistic power Beyond AI regulation: How government and industry can team up to make the technology safer without hindering innovation Jennifer D. Oliva currently receives funding from NIDA to research the impact of pharmaceutical industry messaging on the opioid crisis among U.S. Military Veterans. She is affiliated with the UCSF/University of California College of the Law, San Francisco Consortium on Law, Science & Health Policy and Georgetown University Law Center O'Neill Institute for National & Global Health Law.
Forbes
06-05-2025
- Health
- Forbes
Seven Things To Know About Medicare Part D And Prior Authorization
Prior authorization is becoming a bigger issue with Medicare Part D drug plans. getty Over the last several years, prior authorization has become a hot topic. Nearly all those who have Medicare Advantage plans must deal with it for medical services. You've seen the news stories about the denials and their impact on care. A new rule that will be implemented fully by 2027 is supposed to help resolve the issues but time will tell. Now, in 2025, a new wrinkle – prior authorization problems with Part D prescription drugs. Drug plans have required authorization of select medications since the program started in 2006. However, I have received several calls and emails about problems getting approval, a new phenomenon for me this year. Because of the Inflation Reduction Act and the $2,000 cap on out-of-pocket drug costs, Part D drug plans are picking up a larger share of the costs. So, they want to make sure they pay only when it is appropriate. Prior authorization is one way to ensure that. Since more enrollees seem to be dealing with this issue, here are some things to know. The top-three reasons on my list all connect to reducing the costs a plan may have to cover. There is a lower-cost alternative drug for the situation. Part A, hospital insurance, or Part B, medical insurance, should cover this drug, not the Part D plan. This drug being prescribed is not for a medically accepted indication. Part D generally doesn't cover a drug for off-label use, unless it's medically necessary, which may not be easy to prove. Other reasons for authorization can include: Drugs with special monitoring requirements Certain dosages or forms of a medication Controlled substances, and Drugs that may interact with other drugs. A man shared with me his issue with prior authorization. His 'rep' found a new plan that would save him several hundred dollars on premiums. However, now he cannot get a Tier 5 specialty drug approved. He is mad at his rep for recommending that plan. Each drug plan identifies the drugs that will be subject to authorization. It's very possible that costly Tier 4, non-preferred brand, and Tier 5 drugs will require it. After a quick check, I discovered that every plan in the man's area required authorization for his specialty medication so there was no escaping it. I have also seen many Tier 3, preferred brand, and even an occasional Tier 2, generic drug, requiring authorization. Every drug plan has its own procedure and form. Another man reported that he had been waiting almost two weeks for approval. A drug plan representative told him they could not approve the request because his physician submitted the wrong form. The insurers' forms I reviewed range from one to nine pages with some similar questions but enough variation to make using the right form important. You can find the right form by searching 'Part D prior authorization form for (name of drug plan).' Calling the plan is another option but trying to get through to the person who knows something about authorization could be difficult and time-consuming. The prescriber or the drug plan member can submit the request. I heard from a woman who ran out of her medication. When she went to get the drug on a Sunday, she was shocked to discover the new plan requires authorization. So she asked the pharmacist to do this. Pharmacists know the medications but usually are not the prescribers. The physician or healthcare practitioner who knows the rationale for a particular drug would be the best one to handle authorization. But, in a pinch, the plan member has the ability to do this with a supporting statement from the physician. The form must be completed, in its entirety, with information to support the need for the medication. When preparing the authorization form: Follow the instructions. Include a pertinent diagnosis and relevant history, symptoms, or findings. Explain why other drugs (especially less costly ones) likely won't work (could have adverse outcomes or not be as effective). The process can take time. The same woman thought the pharmacist could get authorization simply by calling the drug plan. Even if the pharmacist could connect with the right person during a weekend phone call, it's very unlikely that the plan would grant authorization. After receiving the form and supporting documentation, the plan has to notify the prescriber and enrollee withing 72 hours for a standard determination and 24 hours for an expedited one. Being proactive may help prevent some of the problems Obtaining prior authorization is generally a physician or prescriber issue. However, when able, Part D enrollees should take some responsibility to smooth out the process as much as possible. Here's a list of some things you can do. Know whether any of your drugs are subject to authorization. Find that information in the plan's documents or the Medicare Plan Finder. Do not wait until the last minute to deal with this. Discuss the situation with your physician. If possible, provide a copy of the plan's form. Watch for notification from the drug plan. Review other plans during Open Enrollment. You might find one that doesn't require authorization. But then, check the trade-offs – how this plan works and how much you might pay. Remember, of course, that determining and obtaining prior authorization when necessary is generally your provider's responsibility. But you obviously have skin in the game. So, pay attention and never hesitate to ask your provider if there's anything you can do to facilitate the process.
