When prior authorization becomes a medical barrier

Slowly but steadily, Marlene Nathanson was recovering. She had suffered a stroke in November 2022 at her home in Minneapolis and spent a week in a hospital; then, when she arrived at the Episcopal Homes in St. Paul for rehabilitation, she could not walk. Weakness in her right arm and hand left her unable to feed herself and her speech remained somewhat slurred.

But over three weeks of physical, occupational and speech therapy, she was making good progress, said her husband, Iric Nathanson. Her therapists were very encouraging. Mrs Nathanson, then 85, had started to get around using a walker. Her arm was getting stronger and her speech was almost back to normal.

Then, on Wednesday afternoon, one of her therapists told the Nathansons that their Medicare Advantage plan had denied a request to cover further treatment. She has to leave our facility by Friday, the therapist said, apologetically.

Mr. Nathanson, then 82, felt anxious and angry. He did not see how he could organize aides and equipment for home care in 48 hours. Besides, he said, it didn’t seem fair that therapists and professionals couldn’t determine the course of her care and had to submit to the dictates of an insurance company. But apparently it happens a lot.

Makes. Traditional Medicare rarely requires so-called prior authorization for services. But virtually all Medicare Advantage plans use it before agreeing to cover certain services, especially those with high prices, such as chemotherapy, hospital stays, nursing home care and home health.

Most people encounter this at some point if they stay in a Medicare Advantage plan, said Jeannie Fuglesten Biniek, associate director of the program on Medicare policy at KFF, the nonprofit health policy research organization. After years of strong growth, more than half of Medicare beneficiaries are now enrolled in Advantage plans, which are administered by private insurance companies.

In 2021, those plans received more than 35 million prior authorization requests, according to a KFF analysis, and rejected about two million, or 6 percent, in whole or in part.

The rationale that plans use is that they want to prevent unnecessary, ill-advised or wasteful care, said David Lipschutz, associate director of the nonprofit Center for Medicare Advocacy, which often hears complaints about prior authorization from both patients and providers. by health care providers. But, he added, it’s also a cost-control measure. Insurers can save money by limiting coverage; They have also learned that few beneficiaries challenge denials, even though they are right, and usually win when they do.

Medicare Advantage plans are bundled, meaning they receive a fixed amount of public dollars per patient each month and can keep more of those dollars if prior authorization cuts expensive services. Plans are making financial decisions, not medical decisions, Mr. Lipschutz said. (Medicare Advantage has never saved Medicare money.)

Such criticism has been circulating for years, reinforced by two reports from the Office of Inspector General at the Department of Health and Human Services. In 2018, a report found widespread and persistent problems with denial of prior authorization and payments to providers. He noted that Advantage plans overturned 75 percent of those denials when patients or providers appealed.

In 2022, a second inspector general report found that 13 percent of denied prior authorization requests met Medicare’s coverage rules and probably would have been approved by traditional Medicare.

By that point, a KFF analysis found, the percentage of prior authorization denials overturned on appeal had reached 82 percent, raising the possibility that many were not denied in the first place, Dr. Biniek.

However, few denials, only about 11 percent are appealed. Last year, a KFF study found that 35 percent of all Medicare beneficiaries did not know they had a legal right to appeal; 7 percent mistakenly thought they did not have such a right.

Additionally, the appeals process can be complex, a burden for those already dealing with health crises. Insurers can deny more aggressively because they know people don’t appeal, Dr. Biniek.

Faced with denials, patients may pay out of pocket for care that should be covered; if they can’t afford it, some just give up. People don’t get the care they deserve, Mr. Lipschutz said.

Responding to inspector general reports and a growing wave of complaints, the federal Centers for Medicare and Medicaid Services has enacted two new rules to protect consumers and improve prior authorization.

Among other actions, he clarified that Medicare Advantage plans must cover the same necessary medical care as traditional Medicare. CMS will conduct oversight to ensure compliance, the agency said in an email to The Times; its enforcement mechanisms include financial penalties.

Starting in 2026, another new rule will speed up the process, shortening the time in which insurers must respond to prior authorization requests to seven days from 14. (For expedited requests, its 72 hours.) The rule will also require insurance plans to post claims authorization information numbers, review times, denials and appeals on their websites. Next year, plans must adopt a new digital system so plans and providers can more efficiently share information about prior authorization review.

Patients and advocacy groups have powerful allies in their efforts to reform prior authorization; health care providers have also complained. The American Medical Association, the American Hospital Association and other professional and trade groups have called for change; Congressional representatives from both parties have introduced the legislation.

Medicare Advantage makes us jump through so many hoops, said Dr. Sandeep Singh, chief medical officer of the Good Shepherd Rehabilitation Network in Allentown, Pa. It has created such a stress on the health care system. A few years ago, his organization had an insurance verification specialist whose job it was to handle prior authorization requests and appeals; now, it employs three.

Previous authorization has delayed admissions, said Dr. Singh. It has driven patients away from specialty hospitals like Good Shepherd, with intensive care hours, to standard nursing homes or home care, he added, where patients receive fewer hours of therapy and face higher rates of re- hospitalization. It diverts staff time that would be better spent on patient care.

On a recent weekend, Dr. Singh spent two hours coordinating and delivering an appeal for a patient with spinal cord injury and brain trauma. After 19 days at Good Shepherd, she goes a long way, but she can’t be home alone safely, he said. However, her insurer was telling us to remove her now. Instead, he decided to extend her stay pending appeals on the prior authorization. “Unfortunately, we will have to absorb costs of about $1,800 a day,” he said.

Will the new Medicare rules make a difference? So far at Good Shepherd, we continue to see the same level of resistance from Advantage plans, said Dr. Singh.

Mr. Lipschutz, of the Center for Medicare Advocacy, said, “It’s clear the intent is there, but the jury is still out on whether it’s working.

It’s about implementation, he said. However, he noted a lesson from the researchers: it pays to appeal.

Usually. Earlier in 2022, Mr. Nathanson received a diagnosis of prostate cancer. His oncologist ordered a specialized MRI; his Advantage plan said no. But his doctor contacted the insurer and after some time it agreed to cover the scan. Mr. Nathanson is in remission, although he is still irritated by the two to three week delay in his care.

However, the appeal for further rehabilitation at Episcopal Homes for Mrs. Nathanson did not overturn the denial of their insurers. She stayed two more days, which cost the couple $1,000 out of pocket; they felt lucky to be able to pay it.

After breaking her hip last fall, Ms. Nathanson now lives at Episcopal Homes. She, too, regrets that her insurer canceled her health care professionals. I wish I could have stayed with them longer, she said in an email. But I had to go home before I was ready.

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