Think about your last routine checkup or a time when you needed immediate medical attention. Your doctor may have ordered some tests or put you on a new medication. Or you may have needed emergency surgery. You probably thought, “My health plan provider will cover these, no problem.”
When your doctor recommends a treatment, that should be enough for you to get the care you need. But there is a process that can get in the way: prior authorization, also known as precertification or prior approval. Many health insurance providers require prior authorization before deciding whether to pay for a treatment, medication, procedure or test. And this has adverse and serious impacts on patients across Pennsylvania.
Thankfully, the Pennsylvania Legislature recognizes the seriousness of the problem and is working to remedy it. Do you want the red tape to be cut from prior authorization? Keep reading to find out what’s being done
What is prior authorization?
Think back again to the last time you needed medical care. If you experienced a delay in receiving your new medication or getting that procedure done, you can most likely blame prior authorization.
Prior authorization was originally put in place to help control the cost of health care. In practice, it means the insurance company won’t pay for your care unless it approves your treatment ahead of time. It takes time for your doctor to put together the necessary information — and then submit it for approval — and this can lead to delays in your care. However, this process has become more and more complex over time.
And approval is not guaranteed. Many insurers may require you to try “step therapy” or less-expensive medications or health options before “stepping up” to procedures and medicines that cost more. Step therapy — or “fail first” — is another cost-control measure, but it means that your health insurer makes decisions about what’s best for your care. That should be a decision made by you and your doctor.
How can prior authorization impact my care?
Your care could be delayed or denied, which could lead to severe or adverse health impacts. In a 2021 American Medical Association (AMA) survey, 34% of physicians reported that prior authorization has led to a serious adverse event — hospitalization, disability or worse — for a patient in their care.
Step therapy can also be detrimental. Forcing you to try another treatment or medication or get another test may cause severe adverse events, possibly requiring further hospitalization and other treatments.
What is required for prior authorization to be approved?
Your physician and their staff will need to submit administrative and clinical information to your health insurance provider. You also may be required to submit additional information.
This information collection and submission eats up a great deal of time for medical professionals. The 2021 AMA survey found that physicians and their staffs spend an average of nearly two business days per week completing prior authorizations. That means less time spent on your care and more red tape before you get the care you need.
How long does a prior authorization take?
Time is of the essence when it comes to our health and well-being. Prior authorizations, however, aren’t instantaneous. According to Cigna, insurance providers make a decision within five to 10 business days. Urgent requests can be decided on within 72 hours, and that’s too long to wait for care.
What can I do to help change the prior authorization process?
This summer, the Pennsylvania Senate passed a bill to reform the state’s prior authorization rules. The state House is expected to take up the bill this fall. If passed, the bill would:
- Expedite approvals of patient care.
- Reduce administrative burdens for hospitals, physicians and other health care providers.
- Require insurers to create a process for patients and physicians to request step therapy exemptions.
Act now! Pennsylvania legislators are considering the bill, and we need your help in reforming prior authorization rules. Reach out to your lawmakers to express support for this bill, so you can get the care you need without red-tape delays.