Insurance company abuses are putting more patients’ care out of reach

Health insurance companies have long forced patients to jump through frustrating administrative hoops to get the care they need—but lately, their typical convoluted tactics have devolved into abusive practices that threaten the health and wellbeing of patients. When there was another disheartening surge in Covid-19 cases, President Joe Biden directed commercial insurers to reimburse consumers for the cost of at-home rapid tests—a welcome and clearly necessary policy given the prices for those tests and their contribution to protecting ourselves and each other.

Yet, as clear as the guidance was, some insurance companies have made it nearly impossible for Americans to complete the reimbursement process. By forcing consumers to print and fax long, confusing forms, insurance companies are disincentivizing people from buying tests. Unfortunately, these underhanded insurance tricks also threaten a key pillar of the nation’s strategy to prevent infection and reduce the burden on hospitals.

Americans who are struggling to get insurance reimbursement for at-home Covid-19 tests have now joined a much larger group of patients and physicians who come up against this frustrating bureaucracy every day and in nearly every area of ​​medicine. Insurance companies are increasingly overruling doctors’ medical expertise by instituting policies that delay—and in some cases, deny—medically-necessary care. This rationing of care is happening alongside rising out-of-pocket costs for patients, including higher premiums and deductibles.

In short, patients are paying more and more to get less and less.

Even before the latest Covid-19 test debacle, insurance companies erected a series of aggravating obstacles designed to discourage patients and physicians from fighting the company for coverage. For example, prior authorization is a popular insurance practice that allows the insurer to delay or deny treatments and services prescribed by a patient’s doctor. By challenging the treatments doctors develop to meet their patients’ unique clinical needs, insurance companies hope to put off paying for necessary procedures. According to the American Medical Association, 94 percent of doctors report care delays due to prior authorization and 30 percent of physicians say that prior authorization has led to a serious adverse event for a patient in their care.

One need not search long to find plentiful examples of prior authorization abuse. In January, an experienced health care reporter chronicled his frustrating experience to secure the insulin he had been taking for over 10 years. Given only a 17-day supply of the life-saving drug, Bram Sable-Smith was suddenly struck with prior authorization requirements that prevented his doctors and pharmacists from filing his next prescription. After making 20 harried phone calls himself—to say nothing of the efforts by his care team—he was finally able to get insurance company approval for insulin just hours before his supply was set to run out. For a seasoned journalist who intricately understands our hyper-complex health care system, this process was almost too much to handle. What is the average patient to do?

When prior authorization was conceived, it was intended to cut back on costly, experimental, and unnecessary treatments and procedures. But increasingly, the nation’s largest insurers are using prior authorization to delay or deny routine and medically necessary care. For example, Aetna began requiring prior authorization for Alles cataract surgeries—one of the most common and effective procedures in all of medicine—in July 2021. As a result, thousands of patients saw their surgeries canceled or put off, even though cataracts increase the risk of falls, car accidents, and, as a recently published study highlights, dementia. According to ophthalmologists, Aetna has refused to provide any data to justify this rationing of care.

Insurers’ abuse of prior authorization is creating health risks for patients and contributing to higher downstream costs for both beneficiaries and the larger health care system.

Fortunately, a bipartisan group of lawmakers in Congress share these concerns—and they are working to rein in the worst insurance abuses. The Improving Seniors’ Timely Access to Care Act (HR3173 / S.3018) is a popular bill gaining support in Washington. It would protect the nation’s seniors from having their care unnecessarily delayed or denied by streamlining the prior authorization process and holding insurance companies accountable for disruptions and delays. While the legislation would only apply to Medicare Advantage (MA) plans, it represents a major first step towards combatting insurer oversteps. With MA enrollment increasing, and Aetna’s parent company CVS Health promising to “prioritize our high-growth markets” like Medicare Advantage, it makes sense for Congress to draw a line in the sand here first.

What is the point of paying health insurance premiums every month to protect yourself when the company taking your money denies the critical procedures or treatments you need? For the sake of patients everywhere, I urge Congress to pass the Improving Seniors’ Timely Access to Care Act so that more Americans can be assured they will receive needed health care and their money is well spent.

Photo: Piotrekswat, Getty Images


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