![]() ![]() The process of prior authorization aims to establish medical necessity to prevent “unnecessary, costly, or inappropriate medical treatments that can harm patients,” according to Cathryn Donaldson, a spokesperson for the America’s Health Insurance Plans industry group. According to an American Medical Association survey released in 2019, 88% of providers reported that the burden of prior authorization has increased over the past five years, forcing them or their staff to spend an average of two business days a week completing them. Many physicians and health care providers consider the extra paperwork needed for prior authorizations a growing scourge that requires them to expand their staff to handle the back-and-forth with insurers. The Push-And-Pull Of Prior Authorizations Subscribe to KHN's free Morning Briefing. Oftentimes, approval conversations happen primarily between the insurer and the provider - leaving the patient further in the dark when the bill appears. In other cases, a patient will be told that no prior authorization is needed for a certain intervention, only to hear afterward that the insurer wanted one in this particular case. Prior authorizations may now include a line or two saying something like: “This is not a guarantee of payment.” This loophole allows insurers to change their minds after the fact - citing treatments as medically unnecessary upon further review, blaming how billing departments charged for the work or claiming the procedure was performed too long after approval was granted. While doctors and hospitals chafe at the administrative burden, insurers contend the review is necessary to ferret out waste in a system whose costs are exploding and to ensure physicians are prescribing useful treatments.īut patients face an even bigger problem: When insurers revoke their decision to pay after the service is completed, patients are legally on the hook for the bill. Those preapprovals are frequently time-limited. While prior authorization was traditionally required only for expensive, elective or new procedures, such as a hip replacement or bypass surgery, some insurers now require it for even the renewal of some prescription drugs. ![]() The billing quagmire into which the Markleys fell is often called “ retrospective denial” and is generating attention and anger from patients and providers, as insurers require preapproval - sometimes called “prior authorization” - for a widening array of procedures, drugs and tests. “You can go from an upstanding middle-class American citizen to completely under the eight ball.” “I feel for anyone that finds themselves in that predicament,” said Markley, a nurse who was pursuing her Ph.D. Markley said she never would have had the tests done if she had known insurance was not going to pay for them. The Markleys review their medical paperwork. Markley had tests authorized that were later denied.” By 2014, five years after her initial hospitalization, they had no choice but to declare bankruptcy.Īnthem Blue Cross and Blue Shield spokesperson Leslie Porras said company “records do not indicate that Ms. Even after Mayo wrote off some of what they owed, her disability and Social Security checks barely covered her insurance premiums. While Darla learned to walk again, the Markleys tried to pay off the bills. But after the tests found she also had beriberi, a vitamin deficiency, Anthem Blue Cross and Blue Shield judged that the tests weren’t needed after all and refused to pay - although Markley said she and Mayo had gotten approval. The more than $34,000 in medical bills that contributed to Darla and Andy Markley’s bankruptcy and loss of their home in Beloit, Wisconsin, grew out of what felt like a broken promise.ĭarla Markley, 53, said her insurer had sent her a letter preapproving her to have a battery of tests at the Mayo Clinic in neighboring Minnesota after she came down with transverse myelitis, a rare, paralyzing illness that had kept her hospitalized for over a month. This story can be republished for free ( details).
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