Prior Authorization Endangers Patients

November 28, 2018

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Why are health plans permitted to tell doctors how to practice medicine?  Have you questioned this dangerous assertion of corporate power over the physician, who has 11 to 15 years of training, or have you just accepted it?

To get access to the health plan’s captive enrollees, physicians sign contracts with plans that often require them to comply with the plan’s prior authorization requirements. These requirements often hurt patients, and are wholly unethical. 

Prior authorization (“PriorAuth”) is the process that requires physicians to ask the health plan for permission to treat the patient the way the physician—the only one in the room with the patient and the only one with a professional obligation to the patient—believes the patient should be treated. In short, PriorAuth is how the health plan controls doctors, restricts access to care, and generates profit. 

Health plans and their PriorAuth requirements are embraced by Congress.  Single-payer supporter, Senator Ted Kennedy got the HMO Act of 1973 passed to establish HMOs, now called health plans, nationwide. HillaryCare would have used HMOs to run a national health care system. Medicare Advantage (the HMO/health plan version of Medicare) became law in a GOP Congress. The Democrat’s Affordable Care Act (ACA) forced almost everyone into a health plan and gave them billions in federal subsidies. And most GOP “repeal” proposals include continued generous taxpayer-funded subsidies to health plans through ACA “state innovation” grants. This redistribution program to enrich health plans is called “reinsurance.” 

PriorAuth endangers patients.  According to an American Medical Association study reported this month, 92 percent of physicians believe PriorAuth has a negative impact on clinical outcomes. Waiting for permission from a health plan delays treatment. Importantly, 72 percent of surveyed physicians in May said PriorAuth can lead patients to abandon a recommended course of treatment. Medical practices complete an average of 30 PriorAuth submissions weekly, and spend an average of 14.6 hours per week working on data entry and other tasks related to processing and submitting them.

PriorAuth is a menace to patients and doctors alike. For example, the AMA notes the following written comments from two individuals:

“When I started here the only procedures requiring prior authorizations were surgeries,” wrote Robin S., who works at a urology practice. “Now medications, radiology and in-office procedures require prior authorization or you do not get paid.”

“I have had to make multiple calls and wait as long as two weeks trying to obtain authorization for an MRI when there were abnormal mammogram or pelvic sonogram findings,” wrote Dr. Nina S.

What if you were Dr. Nina’s patient?  America isn’t yet Canada. We don’t have a single-payer system. But we are embracing a corporateversion of socialized medicine, causing delays, denials, and dangerous outsider control of doctor’s decisions. 

In a free society, this is unacceptable. Ask Congress to repeal the ACA prohibition on real insurance: catastrophic indemnity medical insurance, also called Major Medical.

Let’s bring real (and affordable) medical insurance back.

In freedom,

Twila Brase, RN, PHN
President and Co-founder