Prior Authorization Hurts Health Care Outcomes

By Consumers for Quality Care, on July 24, 2024

Prior authorization is making it needlessly difficult for consumers to get the medical care they need, according to the HeraldNet. 

Although prior authorization is meant to be a cost-cutting measure, patient advocates suspect that some insurers are abusing it to deny patient care. Robin Sparks, 61, of Marysville, Washington was diagnosed with Stage 3 non-Hodgkin lymphoma in 2022. Her doctors wanted to check on her progression midway through her six-month chemotherapy treatment by ordering a CT scan. But Sparks’ insurance company, Ambetter, denied the request, saying only that the CT scan was “just not necessary.”  

Dr. Brandon Tudor, an Emergency Physician at Overlake Medical Center in Bellevue, Washington, said that prior authorization also adds a significant amount of time-consuming administrative work for health care providers. This is in addition to causing life-threatening delays in critical care. According to a 2023 American Medical Association (AMA) survey, one in four prior authorization requests are denied. 

The Centers for Medicare & Medicaid Services (CMS) took action earlier this year to address prior authorization. The agency finalized a new rule requiring insurance companies to tell consumers exactly why they were denied. The rule also requires insurers to use more efficient electronic record keeping tools to expedite processing, and it limits how many times insurers can require prior authorization. The new rule is expected to save both patients and health care providers roughly $15 billion over the next decade, in addition to speeding up approvals for critical health care.  

CQC applauds efforts to reform the prior authorization process and urges both lawmakers and providers to eliminate burdensome procedural hurdles that prevent consumers from receiving the medical care they need.