When Kathleen Valentini had a nagging pain in her hip that would not go away, she eventually saw her primary doctor. The 47-year-old North Carolinian was sent to physical therapy and given pain medicine, yet her pain persisted and caused difficulty walking.
She was referred to an orthopedic surgeon who was concerned and ordered an MRI. Valentini’s insurance company denied the MRI, stating that the scan was not medically necessary and that she had not yet completed physical therapy. In fact, she had finished therapy and the insurance company had already paid for the service. She would eventually die from cancer in the hip.
The process of approving a procedure, medication or medical treatment is called prior authorization. Insurance companies purport that it is a tool to ensure medical treatments are necessary and appropriate. When used correctly, prior authorization can lead to efficient care and reduced costs, providing an appropriate check and balance to keep health insurance premiums affordable and ensure that medical care is reasonable.
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Ask many physicians, and you will hear that prior authorization is increasingly being used to deny or delay basic medical care such as blood tests, imaging and other medically necessary procedures. The added friction from this process leads to inefficiency, increased costs, delays, prolonged suffering and physician burnout in healthcare.
Prior authorizations, including subsequent denials and appeals, take enormous time and resources for patients, physicians and staff. Notably, wait times to speak with a health insurance company representative can be over one hour.
Some insurance companies have employed disturbing tactics to delay or deny care. In my neurosurgery practice, one insurance company gave only four hours to appeal a denial for necessary medical care. Others have denied claims without reviewing my clinical notes on the patient.
According to the AMA, there are approximately 41 prior authorizations per physician per week, taking up two business days of physician and staff time. This administrative burden is contributing to physician burnout and has led some doctors to stop working with certain insurance plans.
This problem has been particularly alarming in Medicare Advantage plans. A 2023 Kaiser Family Foundation analysis found that 82% of appeals in Medicare Advantage plans resulted in overturned denials. In some plans, more than 90% of denials were overturned, raising serious questions about the number and nature of these denials.
Insurance companies argue that the denial of payment does not prevent a patient from following through on a doctor’s orders, but most of my patients cannot pay for an MRI, spine surgery, hospital stay or rehabilitation that can sometimes follow.
Appealing these denials can lead to a discussion with an insurance company doctor known as a “peer-to-peer.” However, these discussions rarely happen with a physician in my own specialty of neurosurgery. Lacking the professional background, these gatekeepers must then be convinced to allow a needed treatment course to proceed.
This exchange can be awkward and frustrating on both sides. An analogy would be a banking attorney giving advice on a capital murder trial.
Some hope may be on the horizon. The Centers for Medicare and Medicaid Services issued rules to reduce the friction of prior authorization with an automated electronic process and to add transparency to the process.
Congress is considering legislation, the Improving Seniors’ Timely Access to Care Act, which would further streamline prior authorization in Medicare Advantage plans. There is a bill pending in the Nebraska Legislature to exempt providers with greater than 90% appeal approvals. Moreover, the Nebraska Department of Insurance should collect and investigate complaints from health care providers on behalf of patients.
Physicians have little recourse for unscrupulous behavior by insurers, and this would allow regulators to observe and act on patterns of abuse. Lastly, regulators should require that health insurers use physicians in the same specialty during a “peer-to-peer.”
The misuse of prior authorization has the end effect of wearing down physicians and patients who must navigate the byzantine process. In the best case scenario, the process delays care, prolongs suffering and adds significant administrative costs to health care.
In the worst case scenario, people get hurt. Kathleen Valentini’s case highlights what can go wrong. Her orthopaedic surgeon appealed the denial, and the MRI was eventually performed nearly six weeks later. She underwent surgery to remove her leg, part of her hip and pelvis. Her cancer doctors said she could have avoided surgery had the tumor been discovered only weeks earlier.
We should expect better from our health insurance.
