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February 3, 2020

Changing the Game of Prior Authorization: The Patient Perspective

Author Affiliations
  • 1Center for Patient Partnerships, University of Wisconsin, Madison
  • 2University of Wisconsin Law School, Madison
  • 3Editorial Affairs, Institute for Healthcare Improvement, Boston, Massachusetts
JAMA. Published online February 3, 2020. doi:10.1001/jama.2020.0070

Securing approval for reimbursement of care in a medical care system affected by overuse and ineffective care seems logical and arguably protective of patients’ interests. However, the prior authorization process has now become a significant burden on clinicians, patients, and health care organizations. Even though some organizations are actively advocating to reduce the financial implications and time requirements caused by this process, the full effects and consequences of prior authorization on patients and their families (particularly reversals of authorization after the fact) remain enormous. Along with whatever protections against unnecessary care that it offers, prior authorization has created a minefield of financial risks for patients and their families.

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    2 Comments for this article
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    Preauthorization Disclosure
    Gretta Gribble, AN, BSN | None
    There are many reasons for issuing a preauthorization disclosure ("this is not a guarantee of benefits") but most of them have nothing to do with determining if a treatment/procedure/medication meets the insurance contract requirements.  I have never seen a preauthorization not honored for clinical reasons, assuming that the record supports any verbal statements.  The reason for reading this has to do with contract details - for instance, the patients' employer or the insured is not paying the insurance company and the contract is cancelled at the same time the preauthorization is in process.  You would be surprised how many patients do not understand this circumstance ("but you said it would be covered").  Other reasons for denial generally would be related to the contract, not the medical indication.
    CONFLICT OF INTEREST: None Reported
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    Doctors and Patients - Not Insurance Companies - Should Determine the Course of Patient Diagnostics and Treatment.
    Richard Fleming, PhD, MD, JD | FHHI-OmnificImaging-Camelot
    The practice of medicine has changed from taking care of patients, to determining what testing, drugs and hospitals may be available to the patient based upon their insurance policy. Nowhere during the time I was in Medical School was the emphasis placed upon the insurance company. Rather it was placed upon the patient and what was needed to correctly diagnose and treat them. We were after all being trained to take care of patients - not insurance companies, CMS or BigPharma.

    When I was in Residency and Fellowship, we learned that the fastest way to get approval for patient
    admission to the hospital was to ask for the name of the person - working for the insurance company - after we were denied permission to admit the patient. The conversation followed that we needed the name of the person for the medical record, so if the patient had complications resulting from the failure to admit them, the record would reflect who the attorneys should contact. It's amazing how those working for the insurance company suddenly find a reason to admit the patient.

    I agree with the need to hold the insurance companies accountable for their decisions about testing and treatment options - but more importantly, I think it is time the control of medical care of the patient return to the doctor and patient.
    CONFLICT OF INTEREST: Patent for Nuclear Imaging Protocol
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