Are Healthcare Insurance Requirements Getting Out of Control?

For many, both patients and physicians, prior authorization in the U.S. is infuriating. When it was introduced, prior authorization was only needed for the most costly types of care in an attempt to reduce the costs of treatment. Today, even the most standard medical recommendations can have insurance requirements before any action can be taken. So, what was originally designed to protect against unnecessary, expensive treatments, has become a roadblock to patients getting the care they need.

Particularly frustrating is how long the process takes. An initial request can take weeks to receive an answer, and even then, a lot of claims are denied. Considering a KFF report that states 82% of appeals for denied requests to Medicare Advantage plans resulted in the denial decision being overturned, it seems that prior authorization is an unneeded hoop to jump through to provide appropriate care to patients, and many of our Figure 1 HCPs agree.

What the Figure 1 Community Thinks

We asked the Figure 1 community for their thoughts on prior authorization and it came as no surprise that HCPs are, in general, not fans of insurance requirements. More than 80% of the respondents claimed that prior authorization has negatively impacted their practice and their patients. With 10% saying there was no impact, that leaves less than 10% of respondents who said prior authorization has had a positive impact.

The most common frustration our respondents described was that this long process seems to undermine the decisions of HCPs with no value added for the provider or the patient. One podiatrist responded stating that “if insurance thinks that providers are incompetent and need to prove that their decisions are standard of care and not harmful to the patient, then the provider’s time should be compensated.” Ultimately, compensating HCPs for dealing with insurance requirements may actually be a cost effective idea since, as hematologist Dr. Julie Kanter states, “it’s more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and patient more.”

Is It Getting Worse?

When asked if the volume of prior authorizations has changed over the past few years, 77% of our respondents said yes, it has increased. Considering that 56% of respondents said that time spent on prior authorizations always delays patient care and an additional 26% said that it often delays care, having increasing levels of prior authorization can easily mean less time caring for patients.

Hope for the Future

While the difficulties of prior authorization do seem to be getting worse, there is recent news that could mean the future of insurance requirements may get better. In 2022, the U.S. government proposed changes which would require healthcare plans to speed up the response process to seven days (three for urgent requests) and provide more information about denials. While many still believe the proposed seven-day timeline is still too long, these changes may, at the very least, help improve relationships between providers and patients. 

One of our respondents wrote, “At least require all insurers to publish their preferred meds and tiers for others … embed this in the EMR so it is easy to see when ordering a drug. Patients blame me when we have a delay because of the PA process.” 

There is likely a long way to go before prior authorization is something the healthcare community finds useful. However, these proposed changes may help make insurance requirements easier to understand and reduce the time waiting to see if patients can get the care they need.

Published March 27, 2023

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