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Need Surgery? Ask Your Insurance Company First

" we have prior authorization for this? Image by skeeze from Pixabay

Have you ever gone to the doctor and been told you couldn't have a prescription drug or a surgical procedure without it being first approved by your insurance company? And then you had to wait for days or even longer before that approval came? And then you had to get another appointment with the doc?

That's been happening to increasing numbers of people who participate in the Medicare Advantage HMO-based program, which essentially ties them to doctors who participate in their plan and subjects them to the prior authorization rules established by that insurance company. Those rules are designed to prevent unnecessary procedures and save money.

In other words, to provide healthcare as cheaply as possible.

It's not simply a problem of inconvenience to patients and of time-consuming administrative headaches for doctors' offices. According to a recent survey, it's having a serious impact on healthcare and is negatively affecting patient outcomes.

In fact, it's so serious that many patients -- 82 percent -- often or sometimes abandon treatment altogether. All this happens while doctors are forced to add staff just to handle the requirements of the insurance companies to complete prior authorization paperwork.

And then, the survey shows, even though more than 70 percent of requests are approved, with about a third of doctors getting the OK 90 percent of the time, three-fifths of physicians report that the insurance companies then turn around and deny payment for the procedures or medication that they approved.

The problem has reached almost crisis proportions, to the point that a number of specialty providers have banded together to convince a bipartisan group of U.S. Representatives to introduce a new bill to help provide solutions. Two of the sponsoring lawmakers are physicians, one a Republican, the other a Democrat.

The bill is sponsored by Reps. Suzan DelBene (D-WA), Ami Bera, MD (D-CA), Robert Marshall, MD (R-KS), and Mike Kelly (R-PA). It is based on a consensus statement adopted by leading national organizations representing physicians, hospitals and health plans – The American Hospital Association, America’s Health Insurance Plans, the American Medical Association, the American Pharmacists Association, BlueCross BlueShield Association, and the Medical Group Management Association.

Last year, over 100 members of Congress called for such reform in a bipartisan letter to the Centers for Medicare & Medicaid Services (CMS).

According to Rep. Bera, MD, the legislation would improve the prior authorization process in Medicare Advantage (MA) plans through improved transparency, electronic adoption, and an analysis on the items and services subject to prior authorization.

"Of all the much-needed updates to prior authorization, none is more critical than ensuring that, for routinely approved services, health plans make prior authorization available in ‘real time’ so that physicians and their staff have more time to spend on patient care, rather than paperwork,” Dr. Bera said.

In addition, the bill includes a surgical exception that allows the surgeon to rely on the initial authorization if he/she needs to perform additional services while the patient is in surgery.

Can you imagine? You're on the table in the OR and the doc says, "Well, it's clear that we need to remove this patient's gall bladder, but we better button him up until the insurance company gives us authorization."

That can't be allowed to happen.

“Physicians spend far too much time on burdensome paperwork and seeking authorization on certain items, when they can be spending that time taking care of their patients," said Dr. Bera. "This bill modernizes the process and is a win for physicians and patients.”

“When seniors need critical medical care, doctors and support staff should be spending their time working with patients instead of having to haggle with insurance companies over whether they can do their jobs,” Rep. DelBene declared. “This bipartisan legislation creates sensible rules for the road and will offer transparency and oversight to the prior authorization process."

Hopefully, common sense will prevail on Capitol Hill and this legislation will be approved and then signed into law. Seems to me our lives could depend on it.

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