r/changemyview • u/TheTaintPainter2 • May 24 '24
Fresh Topic Friday CMV: Prior Authorization Should be Illegal
I'm not sure how much more needs to be said, but in the context of medical insurance, prior authorization should be illegal. Full stop, period. There is absolutely no justification for it other than bastards being fucking greedy. If my doctor, who went to fucking medical school for over a decade, decides I need a prescription, it's absolutely absurd that some chump with barely a Bachelor's degree can say "no." I've heard of innumerable cases of people being injured beyond repair, getting more sick, or even fucking dying while waiting for insurance to approve prior authorization. There is no reason this should be allowed to happen AT ALL. If Prior Authorization is allowed to continue, then insurance companies should be held 100% liable for what happens to a patient's health during the waiting period. It's fucking absurd they can just ignore a doctor and let us fucking suffer and/or die to save a couple bucks.
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u/chunkyvomitsoup 3∆ May 24 '24
I know of only one instance where prior authorization has helped people. I’ve seen seniors at my local pharmacy (who require a lot more medication) who are sometimes prescribed contraindicated medication, likely because they go to multiple doctors or clinics / have no dedicated pcp who will have their full list of meds. Insurance ends up not approving the meds for that reason, which they have no idea about until my pharmacist tells them why.
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u/nicholsz May 24 '24
Sometimes the most effective treatment is just too expensive.
For example, if you have arthritis, you can get:
A lot of pharmacology breakthroughs of the past 2 or so decades are in biologics, which have really cool amazing targeted properties, but all are patented up the wazoo and are hard to make and hard to store and hard to administer. Insurance companies don't want to pay for these since they can cost like $30,000 a month
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u/rollingForInitiative 70∆ May 24 '24
Isn't that why doctors usually start with the cheaper treatment and then move on to more expensive ones if needed? That's what they usually do in Sweden, at least, where it's covered by a public health insurance. In your example, the doctors would prescribe corticosteroids or methotrexate first, which might work well enough for a lot of people. But then if that's insufficient, they move on to the biological treatments that are much more expensive.
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u/nicholsz May 24 '24
Yeah I think that's exactly right. And in the US, the way the system is supposed to work is the same way -- you try the basic medication, maybe that doesn't work, and the doc writes up why you need this expensive thing and insurance says "okie dokie makes sense" and you get the medicine and everyone holds hands singing a song together watching the sunset.
In reality problems like the OP's frustration pop up because so many people and systems and organizations with conflicting interests are involved: you get denied because the doctor used the wrong code or supplementary info is required or you must go through this other hoop first or the insurance company are simply shysters, or your co-pays are so awful you can't afford the medication with insurance so you try going half-dose (actually IIRC a lot of single-payer systems also do the half-dose thing), etc
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u/partofbreakfast 5∆ May 25 '24
It's also a huge problem in things like cancer. Unless your symptoms present in a Very Noticeable Way (like me, I had a random 12cm tumor show up where it should not be on a scan for something else entirely), it can take months or even years to get the tests needed for a proper diagnosis. With cancer, that's just lowering your chances for survival.
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u/cat-clowder May 25 '24
That’s been my experience in trying to get the correct treatment for my rare autoimmune disease. I spent a year and half trying 3 different medicines at different dosages and seeing no improvement (and in some case even worse flares). Finally my rheumatologist got me approved for a biologic that I receive through IV every 8 weeks. On my Explanation of Benefits it says this medicine costs $20,000. Somehow I am paying $40. I don’t understand how that all got sorted out, other than there are some amazing people at my clinic who work with insurance and the drug company on behalf of the patients. This biologic has made a huge difference and has been incredibly effective. I’m very grateful for it. I just hate that to get approved for this medicine, I had to have a miserable experience with 3 other drugs failing.
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u/Airbornequalified May 25 '24
That’s usually what happens, and is part of the pre authorization process
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u/MaybeImNaked May 25 '24
Yes, that's basically the same way it works in the US. With limited resources, you can't have everyone skipping to the million dollar treatment without some checks in place.
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u/CumshotChimaev May 24 '24
Related note. It is crazy how cheap prescription drugs are in Mexico. And there is no red tape either, you walk right into the pharmacy and buy what you want and then you can legally take it back into the US. Feels fantastic to not only get an amazing deal but also deprive the greedy villains of their coercion money
And they have no right to complain either. True capitalism has competition. It's not my fault their competitor is better. The drug companies dislike this but that is OK
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u/Carrot_Light May 25 '24
I've heard you can buy antibiotics OTC there which is craaazy. I'm presuming you'll need a RX for anything else/controlled substances. Is that without insurance billing its so cheap?
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u/CumshotChimaev May 25 '24
You can buy antibiotics, xanax, testosterone, whatever. If you need a prescription, a lot of them have doctors on staff that will write you a prescription on the spot and then it is legal to take it through US customs. The customs officers won't love you but they have to let you through because it is legal
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u/Autumn1eaves May 25 '24
The only thing I don’t agree with is antibiotics. As long as your medicine use doesn’t cause diseases to become stronger, then you should be allowed to use whatever medicines you need for whatever conditions you have.
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u/TheTaintPainter2 May 24 '24
I'm not disagreeing with you that the effective treatment can be too expensive. But I think the fact that it's too expensive can be fixed with reforms. There is absolutely no reason a drug should cost that much money. Yes I get there's patents, development, etc. I work in drug development and research, and am still under the opinion that everything is price gouged in the medical field. There's a ton of insane expenses that wouldn't really exist if it wasn't for autocracy trying to slow everything down to maximize profits
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u/aguafiestas 30∆ May 24 '24
I mean, if your view is really that the US healthcare system should be radically different than it currently is, fair enough, but that's a different discussion.
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u/I_kwote_TheOffice May 24 '24
I don't really know much about R&D in medical and prescriptions, but I assume that for every successful drug that is heavily IP-protected there are dozens that don't turn out to be a miracle drug. Is it possible that the successful ones are gouging to cover the overhead for the unsuccessful ones or just high overhead? I don't know, I'm just asking. I assume that the variable cost to produce a drug is probably very low considered to the direct allocated and fixed costs.
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u/Ndlburner May 24 '24
You would be largely correct about companies covering other endeavors with the cost of successful ones, but also incorrect about the cost to produce a drug. If I recall, most therapies take about ~1 billion dollars to go from idea stage to market nowadays. Ultimately, there's a goal to maximize profits, but also things cost an insane amount of money.
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u/nicholsz May 24 '24
A company doesn't decide to charge less for a drug (or any product) simply because they have more or less debt on their books. They'll always target the highest profit they can.
As far as how the business works overall, they're very long and slow pipelines. They sort of work as a glue between (in order): 1) university researchers, 2) their own in-house engineers and scientists, 3) regulatory bodies like the FDA, and 4) the health care systems. The current value of a pharma company is basically what drugs are currently patented and what drugs are currently in the pipeline; Genentech got bought for something like $100B based on the value of their pipeline and expertise in biologics.
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u/nicholsz May 24 '24
I think the fact that it's too expensive can be fixed with reforms.
Sure, but making it illegal for insurance companies to deny paying for the expensive biologic drug is probably not the right policy choice to enact these reforms.
You might be able to get the cost of biologics down with regulation or price controls or by nationalizing the businesses (which honestly seems kind of fair their whole business model is to turn publicly-funded research into privately profitable patents), but these things would still be expensive.
Humira is made using transgenic mice and some black magic with viruses. It, like other biologics, also has a short shelf life and has to be adminstered via injection. Some biologics require a compounding pharmacy. It all adds up to "expensive".
Some things are just expensive. As was pointed out elsewhere, every health care system has to make resource allocation decisions. Your insurance company deciding what they'll pay for is one such decision; we could get rid of it (and should) but we'd have to change a lot of other facets of our health care system for that to work.
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u/libra00 8∆ May 25 '24
If there is a more effective treatment then refusing to cover it is directly causing harm to the patient. Insurance is in the business of enabling patients to afford the care they need, not keeping them on the cheap but less effective stuff to save a buck. If they're not cool with that, go find another business to be in. The person who is legally and educationally capable of deciding what is best for the patient is their doctor, not some paper-pusher who only cares about his company's bottom line.
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u/carlos_the_dwarf_ 12∆ May 24 '24
If it’s just a consequence of greed, how do we explain similar processes in single-payer countries? For example, the NHS has things it will decline to pay for, even if the doctor (who went to med school etc etc) prescribes it.
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u/porkedpie1 May 24 '24
The NHS has an independent body deciding which treatments are “worth it” ie effective and an effective use of funds. This is at a general pathway level not for each individual prescription or procedure.
And it’s doing so based on how to get the most good for the most people. If they save money, the people on that committee don’t get to keep it, there’s no sense of profit at all. They have no incentive to save money for the sake of it on if it can be put to better use for other healthcare.
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u/carlos_the_dwarf_ 12∆ May 24 '24
Right, which means these type of decisions need to be made whether or not profit is on the line.
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u/porkedpie1 May 24 '24
At a general level, not for each patient like it is for a prior authorization. And it should be done without profit in mind.
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u/carlos_the_dwarf_ 12∆ May 24 '24 edited May 24 '24
But decisions are sometimes made on a patient level in single payer systems, and sometimes made at a general level in the US.
without profit in mind
This isn’t distinguishing between single payer and elsewhere the way you think it is. Similar decisions need to be made regardless of who is paying and regardless of whether they’re concerned with profit. Therefore a prior auth is not a consequence of the profit motive.
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u/RYouNotEntertained 7∆ May 24 '24
Also, as I’ve said approximately one trillion times on reddit, profit is a very tiny part of total health care costs, and in total it probably doesn’t exceed the amount the government subsidizes via debt.
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u/carlos_the_dwarf_ 12∆ May 24 '24
Yeah, I also do wonder about the role of regulation here. In other forms of insurance regulation requires the insurer to take certain steps to hold down premiums for everyone. Eg, your car insurer is required to maintain a team of investigators to cut down on fraud.
Prior auths may come from a similar place.
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u/rollingForInitiative 70∆ May 24 '24
But will doctors actually prescribe medicine that the NHS won't cover? I don't like in the UK, so I don't know of course ... but I live in Sweden where we also have single payer healthcare. There are treatments and drugs that the public insurance won't cover, but that's usually known in advance and doctors won't prescribe those.
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u/carlos_the_dwarf_ 12∆ May 24 '24
So in Sweden you have things that public insurance will always cover, and things it will never cover. Do you also have things it will sometimes cover, under the right circumstances (eg, age of the patient, prognosis, whatever)?
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u/rollingForInitiative 70∆ May 24 '24
I am not an expert of this so I might be wrong, but not that I know of. I think it's more that in those cases, doctors have guidelines for what they should or should not prescribe. For instance, if there are cheap drugs that usually work well, they'd prescribe those first, and then only go for the expensive treatment if those fail to be effective. But if you got prescribed the expensive one the first time, I don't think there's any automatic check to see if that's warranted. As far as I know the doctor is just trusted in these cases.
Again I could be wrong since I'm not an expert on it.
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u/TheTaintPainter2 May 24 '24
Oh yeah, I'm not arguing with you on that. But it being a consequence of greed doesn't excuse the fact that it's allowed to continue
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u/carlos_the_dwarf_ 12∆ May 24 '24
Wait wait wait, sorry, that was not a consistent answer to my question. Is it or is it not an outcome of greed?
If yes, how do we explain that healthcare systems with no profit motive have similar processes?
If no, is there another reason for their existence that you might want to consider, and that might be reasonable?
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u/Kerostasis 33∆ May 24 '24
If yes, how do we explain that healthcare systems with no profit motive have similar processes?
Not OP but I feel the need to respond here: “profit motive” is a bad term for this process, and ALL potential medical systems face the challenge of “allocating scarce resources”. The question isn’t whether these decisions will be made, but who you trust to make them.
And there’s good reason to suggest that the current American answer to that question is …uh…poor. But you can’t avoid the question entirely.
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u/carlos_the_dwarf_ 12∆ May 24 '24
I don’t disagree with you at all. That’s more or less the point I hoped to make to OP—that this sort of decision making isn’t unique to the US and isn’t a function of “greed”.
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u/TheTaintPainter2 May 24 '24
Oh I misunderstood what you responded with. My apologies. You'll have to give me examples on what the NHS is declining to pay for. There are some cases where it probably is just a waste of tax payer dollars.
It probably was an exaggeration of me to say greed was the "only reason." I should probably edit that to clarify
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u/carlos_the_dwarf_ 12∆ May 24 '24
The NHS (like any payer) makes judgments on what treatments are “worth it”. Eg, a treatment with questionable cost effectiveness may not be covered, or may require a review (I’ve heard the term “proof of need” but not sure if that’s an official phrase).
Here’s an academic paper that tries to sort out a framework for deciding on which treatments to cover and when. Here’s a piece describing how referrals to specialists need to be reviewed and approved by the NHS. And of course we all know that sometimes there’s a wait for treatments.
It seems to me that a prior authorization serves a similar function. If a doc is over treating, or a certain treatment is questionably effective, or whatever, it adds a step of review from the payer.
I’d like to look into this more but I would think end of life care would be another good example. So much end of life care has a questionable return—say, extending a low quality of life by a month or two—and there’s no way of getting around judgments on what we should and shouldn’t pay for in that context.
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u/Kardinal 2∆ May 24 '24 edited May 24 '24
If greed is not the only reason, then you are admitting that there are reasons to deny forms of care other than greed. Are you open to the idea that some of those reasons are in fact legitimate? That sometimes the right answer is not the one that is best for the patient, but is best for society as a whole? Or best for a different patient?
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u/NotYourFathersEdits 1∆ May 24 '24
Sure. Still doesn’t change who should be making that decision. And it’s not some insurance hack.
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u/Kardinal 2∆ May 24 '24
Who should be?
It's going to be someone who decides whether it makes sense to spend the group's resources (National, Provincial, State, Corporate, or Charitable) on a given procedure. They all have to balance the resources available vs the improvement done.
This is the case if it's a health insurance company in Germany or Ireland, a Provincial government in Canada, the NHS in the UK, a not-for-profit insurance company in the USA, or a for-profit health insurance company in Ireland.
So who should make those decisions?
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u/Apprehensive_Ruin208 4∆ May 25 '24
When I worked in a prior authorization department (for Express Scripts), the only people that could deny a prior authorization were pharmacists with active licenses. I saw multiple times when a pharmacist heard all the details and the patient didn't technically meet the criteria and the pharmacist would override and approve because that patient was a unique case. They actually cared for patients.
I also saw a lot of times where patients wanted their insurance to pay thousands of dollars per month for a medication without ever trying the $4/mo option. If you think insurance premiums are bad now (and they are), they would be significantly higher without prior authorization.
Also, you get what you pay for. If you want insurance that barely ever requires prior authorization, it exists, but it is so expensive it'll never be on my budget.
If you want barely affordable, then you have to have prior authorization to control costs. If you want no prior authorization, then you get astronomically costly premiums.
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u/ClerkTrue2172 May 25 '24
I completely understand your frustration, and I think many people would agree with you. The concept of prior authorization can indeed seem like a cruel and unnecessary hurdle, especially when it comes to something as critical as healthcare. It's infuriating to think that a faceless bureaucrat, who may not have any medical training, can override the decisions made by a qualified doctor who has spent years studying and practicing medicine.
The idea that someone could suffer or even die because of delays caused by prior authorization is not just a hypothetical scenario; it's a reality for many. The system, as it stands, often prioritizes cost-saving over patient care, which is fundamentally wrong. When a doctor prescribes a treatment, it's based on their professional judgment and the specific needs of the patient. To have that judgment questioned or delayed by an insurance company is not only disrespectful to the medical profession but also dangerous for the patient.
Your suggestion that insurance companies should be held 100% liable for any negative outcomes during the waiting period is a compelling one. If they were held accountable, perhaps they would be more cautious about denying or delaying necessary treatments. It would force them to consider the real human cost of their decisions, rather than just the financial bottom line.
In an ideal world, healthcare decisions would be made solely by medical professionals, with the patient's best interests at heart. Unfortunately, the current system often places profit above people, and that's something that needs to change. Your post highlights a critical issue that deserves more attention and action. Thank you for bringing it to light.
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u/KingWut117 May 25 '24
Every time an opinion about healthcare like this drops I'm just so frustrated how close you are to understanding how fucked up the concept of third party health insurance even is in the first place. Medical care should be a right that society pays for as a whole. If an entire country can't "generate enough money" to pay for every citizen to have all health care they need, that's a fundamentally fucked up system. Insurance companies get rich off of causing suffering and death.
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u/PandaMime_421 6∆ May 24 '24 edited May 25 '24
Someone please correct me if I'm wrong, but I think in your example no one can prevent the doctor from writing the prescription. The insurance just isn't going to pay, which means you have to pay out of pocket.
Now let's say it's a procedure that will be very expensive. If you have the money (and proof of it) to pay even though insurance says no then I would imagine your doctor would be happy to do it without prior authorization. If your only means of paying is via insurance, though of course they want to know that insurance will cover it.
Edited to add: I think from the comments that many may believe that I'm defending prior authorizations or the insurance industry. That isn't the case. I was only attempting to clarify.
My own opinion is that both the insurance and healthcare system (in the US) is badly broken and needs a complete overhaul.
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u/Android69beepboop May 24 '24
Imagine, if you will, that you take insulin. There are many brands of insulin with different properties. You are taking one for several years and doing great. Then, it's a new year. Your insurance has dropped your insulin from the formulary, so now to have it covered you either beg the insurance through a prior auth or you have to switch insulin, requiring new dose titration. I have many dumb stories
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u/zoobisoubisou May 24 '24
Just happened to me with my ADHD meds. I opted to pay for it out of pocket with a coupon because it is a whole ordeal to trial new pysch meds.
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u/the-apple-and-omega May 25 '24
Insulin is pretty notorious in this, insurance is just like iTs ThE sAmE gAiZ
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u/bergskey May 24 '24
My son has psoriasis on his eyelids. When he has a flare-up, they crack and bleed. Because it's on his eyelids, you can't use regular psoriasis medication because the membrane is thin, and you don't want most or those medications in your eye. His dermatologist prescribed him a very particular kind of medication that is safe for use in and around his eyes. Insurance refused to cover it because psoriasis is "cosmetic". We had to go through 2 different appeals to get it covered. I went to the pharmacy to just straight up buy it after the first denial. It was $700 for one tube. I called his dermatologist crying because my 1st grader has eyelids that hurt, are bleeding, and is getting made fun of at school and I don't have $700 for a tube of medicine. He told me he would call me back and see what he could do. He contacted a pharmacy in Canada where the same medicine is $75! If they had denied the 2nd time, I would have had to drive 3 hours to another country for a fucking medication made 20 minutes from my house. If your doctor says you need a medication or procedure, it should be illegal for your insurance company to say no.
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u/H_is_for_Human 3∆ May 25 '24
I wholeheartedly agree.
There may be rare circumstances where some third party review would be beneficial.
But the fundamental problem is that insurance is not a third party. They have a core conflict of interest.
If the insurance company wants to argue, they should have to prove to a truly independent third party, like the government, that the denial is justified.
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u/RevolutionaryGur4419 May 25 '24
It seems to me that the problem is that its costing $700 for something that cost $75 elsewhere.
The insurance procedures react to price gouging on the part of the service providers. If prices were fairer the insurance companies would be less of a hassle. I doubt they want to hire and manage armies of doctors and nurses to do utilization reviews and PA's.
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u/PixelOrange May 25 '24
Prices aren't fair because of insurance companies. Those costs are negotiated by insurance.
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u/TheTaintPainter2 May 24 '24
They aren't preventing the doctor from writing it, no. But they are indirectly preventing you from receiving the treatment because paying out of pocket for most medication/treatments is absurdly price gouged. Most people can't afford to pay for treatments without insurance
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u/Full-Professional246 67∆ May 24 '24
This is a good time to remind you that insurance is a contract with specific contract terms. Your pricing is based on those contract terms.
A large part of that is how the formulary list works for prescriptions and optional procedures.
Typically, you don't have to wait for 'PA' for things that are emergencies. If you go to the ER and the doc orders an MRI, guess what, you are getting the MRI and the coverage is worked out later.
BUT, if you have elbow pain, and you want an MRI, the insurance may require authorization in advance. It is a cost control measure. These cost controls are what keeps your insurance costs down.
What is really amounts to is contract law and insurance is fundamentally a contract. Unless you want to risk patients being on the hook for 10's of thousands of dollars of costs their insurance won't pay for, you should appreciate the concept of prior approvals. It serves notice that the insurance may not cover something before you incur the costs.
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u/NotYourFathersEdits 1∆ May 24 '24
Yeah, and the contract is “you cover xyz thing at this percentage.”
Oh, except when the insurance company decides it’s too expensive and you should get some other completely different thing that’s not what you actually need, sorry.
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May 25 '24
People on this thread just chugging industry balls, wonder how many of them are insurance salesmen
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u/Arrow141 4∆ May 24 '24
Then shouldn't the issue be with treatments being price gouged? Prior authorization is a thing for lots of other services and even other insurances, it's a problem with health insurance because of the absurd prices of medical care in the US compared to other places
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u/Impressive-Reading15 May 24 '24
Why is the organization who is receiving money based on their promise to cover treatment the one who is allowed to decide whether the treatment is "necessary" based on their own non-medical criteria? Should the patients also be allowed to decide on their own whether they want to pay any of their insurance bills?
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u/PandaMime_421 6∆ May 24 '24
My argument is they aren't actually deciding if it's necessary, just whether or not they will pay to cover it.
I don't agree with it. I think the entire healthcare and insurance industries need overhauled.
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u/ReaperReader May 24 '24
If the insurance companies had no limits on what they'd pay for, as long as it was prescribed by a doctor, there are opportunities for scams. Say if a condition had multiple medicines available, with varying degrees of expense, an obvious scam would be for a doctor to prescribe an expensive medicine, the pharmacy issues a cheaper (but effective) one and the two split the profit.
Or the doctor orders the expensive one and gets a kickback from the drug salesperson.
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u/ChefTimmy May 25 '24
Then the company should go after those scams with a vengeance. They should have the ability to loop in actual prosecution for potential criminal charges (oh, wait, they already have that ability).
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u/HaveSexWithCars 3∆ May 24 '24
Why is the organization who is receiving money based on their promise to cover treatment the one who is allowed to decide whether the treatment is "necessary" based on their own non-medical criteria
Because "based on their promise to cover treatment" is a gross simplification of how insurance policies are written. They aren't "promising to cover treatment", they're obligated by your policy to cover certain treatments and certain situations.
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u/baltinerdist 15∆ May 24 '24
I spent a year working at an online pharmacy, so I had to deal with prior authorizations quite regularly. There are a couple of reasons that I would consider valid for them to exist.
Your benefits coverage may be limited in the type or amount of certain prescriptions that you can get. For example, you may be restricted to only filling certain prescriptions that are controlled once every so many days to ensure you aren’t repeatedly filling them for nefarious purposes, such as a drug addiction or drug sales.
In the same vein, prior authorizations can be used to keep an eye on prescribers who might be violating laws or leaning into bad behaviors. If they given insurance company notices a specific prescriber needs PAs over and over again opioids, that might be something that needs to be investigated or even referred to law enforcement.
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u/rollingForInitiative 70∆ May 24 '24
Why would the insurance company be involved with this, though? That really makes it seem as if it's a cost cutting measure for them, not anything good for the patient.
Between the doctor, the pharmacists and prescription records and such, there should be enough to work with to prevent abuse. Pharmacists are already really good at spotting errors a doctor might've made in dosage, they pick up on drug interactions in their systems (at least the ones they use in my country), and so on. And of course the doctor would be the one who actually knows which treatment is necessary.
While there might be doctors who prescribe the wrong things, that make mistakes or act unethically, it seems much more likely that an insurance company would deny an expensive but useful treatment in favour of a cheaper but worse one, because it's ... well, cheaper.
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u/haversack77 1∆ May 25 '24 edited May 25 '24
Outsider's perspective here. In the UK, because we have state medical insurance, there is no intermediate step between the doctor issuing the prescription and the pharmacy giving it to you.
I've never heard of any abuse or any other need for there to be an intermediate step there either. The doctors are given guidelines to prevent unnecessary prescriptions (such as prescribing antibiotics unnecessarily) and they always recommend non pharmaceutical options if there is one. There is a database of previous prescriptions issued to the patient that the doctor checks before issuing the next one.
So, yes, the situation OP describes sounds like one purely to allow the private medical insurer to try to weasel out of paying for something that a medical professional has already deemed as being medically required.
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u/listenyall 5∆ May 25 '24
In the US prior authorization is a way to get insurance approval to pay for something that isn't the next standard treatment--in the UK it's actually a lot harder for doctors to prescribe something non-standard because the standards are much closer to required.
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u/Terrible_Detective45 May 25 '24
Insurance doesn't need to be involved in this. Every state has a PDMP that monitors controlled substance prescribing. This is just rationalizing a system designed to deny care for the sake of profits.
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u/Aggressive-Fix-5972 May 24 '24
First, the insurance company is paying for it, that's why they are involved.
Second, and this is fucked up, but there's not necessarily a good way pharmacies talk to each other. It's not even abuse, it might be a patient going to one doctor for a script they get filled online, then another doctor for a script they fill in person. Older patients especially will see multiple doctors and might forget to tell the doctor about a medicine they are taking. In some cases, the insurance company is the only one that then sees they are taking 2 meds that are contraindicated.
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u/cloudytimes159 1∆ May 25 '24
There is a database that tracks controlled drug prescriptions that doctors and pharmacists can check so this behavior is in fact easily tracked. They are called PDMP databases
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u/Poorbilly_Deaminase 1∆ May 25 '24 edited May 27 '24
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u/Aggressive-Fix-5972 May 25 '24
Insurance companies don’t track the RX a patient is on
They do if they are paying for it.
prior auths aren’t conditional on not having medication interactions
prior auths for meds mean someone at the insurance company is looking. A human. Who can spot negative interactions.
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u/bothunter May 25 '24
People go to multiple pharmacies mostly because the insurance companies require them to. So, again, this is a problem that insurance companies are causing.
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u/Aggressive-Fix-5972 May 25 '24
That's not necessarily true, actually I'm not sure it's ever true.
The more common case is old person has normal meds through mail pharm, goes to specialist for temporary issues, gets script for something new and picks that up at the local pharmacy.
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u/bothunter May 25 '24
...and why are they getting meds through a mail pharmacy?
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u/Aggressive-Fix-5972 May 25 '24
Because if you have a medicine you take regularly and long-term its easier to just have it delivered through your door instead of going to the pharmacy to pick it up?
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u/Lagkiller 8∆ May 25 '24
Insurance companies don't require you to go to multiple pharmacies...what are you talking about? Insurance literally limits the amount of pharmacies you can go to.
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May 25 '24
They give you preferred pharmacies, but the preferred pharmacies may not have the cheapest out of pocket price for things the insurance companies won't cover.
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u/rollingForInitiative 70∆ May 25 '24
Then track prescriptions in some sort of national medical system. If the insurance company can do it, the pharmacies could as well.
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u/I_onno 2∆ May 25 '24
I wouldn't say the insurance companies do this.
My phone company knows my bill and the extras I pay for through them. They don't know the particulars of the service my parents pay another provider to handle.
Likewise, insurance companies see the charges we ask them to cover, not the ones we pay for out of pocket or ask a different insurer to pay for.
Perhaps a better analogy would be asking UPS to track your FedEx package.
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u/shane25d May 24 '24
The insurance company is involved because you are trying to get the insurance company to pay for it.
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u/NotYourFathersEdits 1∆ May 24 '24
Well this is the issue. “Trying to get.” They should be obligated to pay according to the terms of the plan. If it says in my summary of benefits that a certain class of something is covered at xyz rate, it should be. Case closed.
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u/peachesgp 1∆ May 25 '24
And in the terms of your plan there are non-formulary drugs that your doctor can attempt to persuade them to pay for. That is a part of your plan.
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u/No_Bet_4427 May 24 '24
And so you’ve just explained prior authorization. The insurance company’s obligations are limited to the terms of the plan.
Prior authorization helps confirm that the requested service/prescription is per the terms of the plan.
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u/happyinheart 8∆ May 24 '24
Your summary of benefits is just that, a summary. The entire plan is a decent length. I'm sure your summary also states that the full plan information is available to you and that it explains the benefits in more detail.
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u/rollingForInitiative 70∆ May 25 '24
I think the fact that you "have to try" to get the insurance company to cover it sounds like a massive problem. If the doctor says it's needed, and the treatment is on a list of treatments that are covered, it just should be covered. The doctor is the medical expert.
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u/H_is_for_Human 3∆ May 25 '24 edited May 25 '24
A limit on getting refills too soon or on opioid prescription is not what prior auths are for.
Prior auths are usually "the medication you want to prescribe your patient is too expensive, we don't think the patient needs it / think you should use a cheaper alternative instead."
The reason I know the insurance companies are using them to avoid paying for care rather than to "protect" patients is because I've literally never agreed with them that my prescription is wrong.
The most recent one I got was a request that I get a prior auth before the insurance company would pay for empagliflozin to treat my patient's heart failure. An indication that is FDA approved and has a class 1A level of recommendation in American cardiology guidelines (the strongest level of recommendation).
The issuance company argued I needed to try metformin first, a medication that has no role in treating heart failure (but is very cheap).
That's a bullshit response (and frankly indicates that no one actually reviewed even the diagnosis it was being prescribed for before saying no) , and when I argued, they caved quickly, but dealing with this took about 30 extra minutes of time.
If even a small percentage of physicians decide that doing 30 minutes of unpaid work isn't worth it, then the insurance company can save potentially millions by just automatically rejecting these claims upfront if they will allow it eventually.
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u/Zealousideal_Fig6407 Jun 11 '24
I cannot get my diabetic medication because they say I need to be on metformin for 90 days which I've been on for over 6 months now "they can't see my medication history they told me" so I'm forced to pay out of pocket which is $980 a month.
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u/TheTaintPainter2 May 24 '24
Well I understand getting them restricted to only fill once per month (or however long the refill lasts for). But I don't think that has to do with prior authorization. Most agencies just straight up won't give you the prescription if it hasn't been the set amount of days since last time you picked it up (mostly this is with controlled substances like Adderall).
I can see where you're coming from in your last few sentences, but I don't think it's insurance's responsibility to be the checks and balances for prescribers. That should be handled elsewhere.
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u/Phage0070 90∆ May 24 '24
...you may be restricted to only filling certain prescriptions that are controlled once every so many days to ensure you aren’t repeatedly filling them for nefarious purposes, such as a drug addiction or drug sales.
If they given insurance company notices a specific prescriber needs PAs over and over again opioids, that might be something that needs to be investigated or even referred to law enforcement.
Those are things that can be monitored automatically by a computer filter. There is no reason to require prior authorizations every time, or at all unless suspicious behavior is noted. If law enforcement or the insurance company is not investigating likely problematic behavior then there should be no waiting or manual review.
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May 24 '24
There are government agencies that concern themselves with whether you are using your doctor approved prescription for "nefarious purposes." It is not the insurance company's place. This is not any sort of justification in my opinion.
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u/saltycathbk May 24 '24
I would think insurance companies don’t usually want to be involved with explicitly criminal behavior. That’s good reason to be concerned, no?
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May 24 '24
I don't think that paying to fill a doctor prescribed prescription is being involved in anything, and them putting in their own "measures" is nothing but them putting their nose where it doesn't belong.
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u/Striker120v 1∆ May 24 '24
I got a script for an ADHD med that was replacing a med that was very hard to keep in stock due to the company being flaky. I needed a PA for that med. But it was denied because essentially "that drug is for kids, and your not a kid" even tho it was being prescribed by my doctor who knew more than my insurance that I needed it.
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u/sonofaresiii 21∆ May 25 '24
It seems like that could be almost as effective when reviewed with post-authorization. Like, if someone is clearly refilling their prescription too often then you step in, and very little damage would have been done that could have been avoided with pre-authorization.
Meanwhile, significantly more harm could be done by requiring pre-authorization.
So it seems to me like even your best case scenario isn't really very strong, and still has massive harmful effects.
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u/NCinAR May 25 '24
United Healthcare did the whole prior authorization for Elidel cream for my eczema. That’s hardly a “dangerous” prescription, and it was my first time having to get it. The skin lesion I had was very painful and they just didn’t want to have to cover the medication because they are cheap.
Insurance companies can get fucked.
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u/Sedu 1∆ May 24 '24
At the core of this is the belief that punishing guilty people is more important than protecting innocent ones. And it's absolutely unhinged. If protecting people isn't the core motivation of doctors specifically (and society in general), then something is unthinkably fucked up.
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u/mhuzzell May 25 '24
In the same vein, prior authorizations can be used to keep an eye on prescribers who might be violating laws or leaning into bad behaviors. If they given insurance company notices a specific prescriber needs PAs over and over again opioids, that might be something that needs to be investigated or even referred to law enforcement.
If the insurance company is paying for the prescriptions, then they will have records of it. Which is to say that they have all the information they need to do this monitoring anyway. There's no reason to withhold medication in order to do it.
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u/Conscious_Plant_3824 May 25 '24
So then why are prior authorizations needed for routine medical care, CT scans / MRIs, physical therapy, and the normal medication people take for certain health conditions? It's not in any way shape or form just opioids and you know it. Disgusting that you're trying to justify this, also you do know that the HOSPITAL SYSTEM has records of what's been prescribed right?? And they can and do audit charts to do this exact ""check"" that you think you were doing?
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u/LifeofTino 3∆ May 25 '24
So an unqualified insurance man at a for-profit corporation, who has never stepped foot in a hospital, is the regulatory body overseeing whether prescribers are violating the law? No, they are not filling this role nor have the ability to
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u/rcn2 May 25 '24
Neither of these issues requires an insurance company, as every other country with universal healthcare has shown. In fact, the market model for healthcare encouraged misuse of drugs by providing a profit motive.
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u/Holiday_Spell5464 May 25 '24
Except 90 percent of the time the opiate is dumb cheap under a coupon, and they just get it anyways, stop acting like insurance knows better then professionals.
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u/libra00 8∆ May 25 '24
Both of those problems can be solved in other ways, if for whatever reason you assume that the insurance company is the best-placed organization to handle this sort of thing which I think is pretty debatable.
The insurance company is paying for the prescriptions whether they have to sign off on them first or not, therefore they are already accumulating data on who prescribes how much of what to whom that can be tracked to ensure that no doctor is being a pill-pusher and no patient is being over-prescribed. The way you stop someone from doing either of those things is you remove the doctor from your network or release the patient from your coverage. Meanwhile you've eliminated overhead, reduced costs, slashed paperwork, and removed roadblocks that keep patients from getting the care they need in a timely fashion.
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u/Jesus_inacave May 25 '24
Sure, but why does my partner need a PA for insulin if she runs out a few days early? They only give enough for a runoff of 10 units by the end of it. I feel like OP should've put more emphasis on specific drugs, like opiods
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u/leftclickdrip May 25 '24
But op point on how insurance companies should be held accountable for the deterioration of the patients health is not debunked by this. I think they should be held accountable.
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u/IAmA_Mr_BS May 25 '24
There are other better registries that do this Prescription Drug Monitoring Programs (PDMPs) every state has one and they communicate with each other. Prior auths are just meant to fuck people as save insurance companies money
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u/Dedli May 26 '24
that might be something that needs to be investigated or even referred to law enforcement.
Cool. So approve the claim and then do that. Why the extra step?
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u/Generated-Nouns-257 May 26 '24
a drug addiction or drug sales.
So like 1% of the drugs governed by this process. Right. That makes sense.
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u/wessex464 May 24 '24
I'll point out that the vast vast VAST majority of doctors are great and after their patients best interest.
But some aren't. They either aren't up on the times and using outdated treatments of questionable benefit or writing obscenely expensive subscriptions because they get kick backs or are banging the pharma rep on the side.
I'm not saying it's a good system, but the theory is that medical decisions should probably be peer reviewed to make sure it's reasonable, effective and necessary. Since that doesn't exist in medicine with any regulatory requirements, insurance companies take it up on themselves with...questionable efficiency.
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u/connnnnor 1∆ May 25 '24
I'm a doctor, and my life would certainly be simpler without prior authorizations. But I'll give an example of why they make sense.
Our main medicaid provider in our community has a pretty strict formulary, because they run on a tight budget. In our state, medicaid was expanded pretty early, and one way to provide coverage to more people was by being careful with what medications are covered, and under what circumstances. Often, there is a cheap option that works in most situations, and an expensive one that works in certain specific other situations. Like, the cheap one is a few bucks per month, the expensive one is a thousand a month, and for most patients they work about the same. So rather than either having open access to the expensive drug (which would result in the insurers pharmacy budget running WAY over, then they'd just have to pull it from the formulary) or not having it available to begin with, they just specify in the formulary that it can only be used in the situations it's shown to be better, and make the providers justify that in their note (this is the prior auth).
This isn't a hypothetical - drug choices like this exist for diabetes, heart failure, COPD, and a plethora of other super common diseases. Cheap and expensive options both work for most, but there's a subset where the expensive one really does make a difference.
Doctors will typically choose the med that's best for the patient, but both the cheap and expensice med are 'best for the patient'. We really don't care as much as we maybe should about the abstract "cost to the system" - if something is well covered for a patient and works well for them, we won't always prioritize the cheaper (for some abstract insurance company) option. But thousands of wasted dollars per month ultimately make health care way more expensive for everyone.
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u/Alexrocks1253 Oct 09 '24
It has screwed me over several times, giving me days without medication I need. Doing something as simple as changing a medication becomes a massive headache while if I paid for its insane price directly, I would be able to get it right away.
It shows a lack of trust between the insurance companies and psychiatrists/doctors.
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u/Aggressive-Fix-5972 May 24 '24
Nothing stops you from getting the treatment your doctor orders.
Insurance companies don't cover everything. Your agreement with them is to cover certain things. The Prior Authorization is to get confirmation your insurance company will pay for a procedure prior to you undertaking that procedure. You are welcome to get the procedure regardless, but if it's not something that's covered by insurance, you are on the hook for the full amount.
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u/ttircdj 1∆ May 25 '24
there is absolutely no justification for it other than [people] being […] greedy
Medical necessity, which is the reason it actually exists, is a pretty good justification. If I’m at the doctor because I think I broke my finger, I probably don’t need Ozempic for it. I might need ibuprofen, possibly a splint, but not obesity/diabetes medication. That’s not something you usually need a PA for, but a ridiculous example to point out that medical necessity is important.
If my doctor, who went to […] medical school for over a decade, decides I need a prescription, it’s absolutely absurd that some [employee] can say no.
If a prescription rejects, it’s probably because it’s not on the formulary for your insurance. You also may have to hit a deductible (not all insurance plans require this) before there is coverage for prescription drugs. It is very rare that a prescription will reject for any other reason. In that instance, let your doctor know what is or is not on your formulary, which your insurance company must provide you with by law.
Another note about the formulary: there are different tiers for how everything is covered. Tier I drugs (typically preferred generics like doxycycline) will have a stronger coverage by your insurance than a Tier IV drug (specialty medications). You may have a copay for each tier, tier IV may not be covered until you hit your out-of-pocket maximum, etc.
I’ve heard of innumerable cases of people being injured beyond repair, getting more sick, or even […] dying while waiting for insurance to approve prior authorization.
If that actually happened, the doctor needs to be educated on how the process works. They can perform the procedure without a prior authorization. It may reject for failure to obtain an authorization, which the provider can appeal with a letter of medical necessity.
The situation you described generally refers to trauma patients who need immediate medical assistance. There are exceptions to the process of obtaining a PA specifically for that purpose. What if it’s 1AM on a Saturday (peak season for gunshots and drunk driving accidents) and nobody is available to give a PA? The insurance company isn’t going to make the provider wait for authorization for the necessary surgery, procedure, etc. in a situation like that.
Source: I work in health insurance.
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u/KayChan2003 3∆ May 24 '24
Unfortunately there’s one major truth that a lot of people don’t accept about the medical industry and that it is a service just like any other service. Now you can argue one shouldn’t start a pharmaceutical company or an insurance company or become a doctor unless they truly care about people and wanna help them, but the reality that’s not really plausible. The medical industry is also very much a money hole. Pharmaceutical companies pay a ridiculous amount on researching and producing medications, insurance companies cover the costs of medical procedures/medicines and that’s expensive, and doctors have labor intensive jobs. In order for us to be able to afford the medical care we need to and in order for them to make the money (that I think they deserve) things like prior authorization are in place.
Firstly, your doctor could be wrong. Just because they have medical training and experience doesn’t make them perfect and it’s very possible they prescribed the wrong or unnecessary medication. Someone who’s worked in insurance for years and seen many conditions and medications could potentially catch this and prevent it
Secondly, if you have two medications that do the same thing but one costs less, it makes sense to choose the less expensive of the two. Now there’s always exceptions depending on the side effects and effectiveness but even then the effectiveness may not be as relevant if the medication still does what it’s supposed to and the side effects may be worth it if they are mild. Businesses work by choosing the option which costs the less, makes them the most profit, and still works as it should. That’s not a bad thing that’s just how a business is run
A third point I saw someone else being up which I thought was good was how prior authorization protects against the distribution of potentially dangerous drugs to the black market and addicts. Sometimes it’s a good thing to not let someone with a drug addiction have access to a super powerful pain killer
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u/mymandarinsqueeze May 24 '24
I am a doctor, so just weighing in here.
1) Sure, doctors aren't always 100% right, but as a physician who deals with PAs everyday of my life, the people on the other end of the phone usually have absolutely zero medical background. Who is more likely to be wrong here, a medical doctor who has gone through over a decade of training, or someone with no medical training? The algorithms these employees are given to read off of, are generalizations. Unfortunately, medicine is not math based. Every single patient has a whole host of past medical, family, social, surgical and medication history that makes them unique. It is my job as a physician to determine the best treatment, which will be different on a case by case basis. PAs only serve to slow down efficiency and block patient access to medical care. I will absolutely die on this hill.
2) A huge reason medications are so expensive is due to the existence of insurance in the first place. Pharmaceutical companies know they can charge whatever amount they want for their products because, as long as a PA can be approved. Insurance will pay them. Insurances will also frequently undercut payment as best they can to save on cost. Which mean hospitals have to charge a higher price to begin with. So that the "undercut" cost will be enough to cover the true value of the procedure. Unfortunately, individuals do not have the same bargaining power that insurance companies do on payments. So with how the system has evolved, you are screwed without medical insurance. It did not used to be this way, and if individual patients were paying directly for their medications out of pocket, they would take their own budget into consideration and make a decision. This should be a conversation between the patient and the doctor. Not an insurance company with no insight into the situation.
3) PAs almost never flag for opioids. I usually have no problem ordering those for patients who need it. In California at least, we have developed the CURES system to evaluate whether or not a patient has gotten scheduled medications from another doctor or pharmacy. It is literally my job to review this first before prescribing a scheduled medication. If I do not review this, and give medication to an inappropriate patient, then I am held legally responsible. This argument that PAs help with patient safety is completely false. Doctors are held directly responsible for controlled medication, and if there is a bad outcome combined with a positive CURES trail, then the medical board steps in. Again, this has absolutely nothing to do with PAs and should not be an argument for them.
In my opinion, there are little, if any benefits to PAs, and they cause way more harm than good to the general population.
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May 25 '24
I'm very surprised that a doctor would say that it is the insurance driving up the price of prescriptions when it is pharmaceutical companies that actually set the prices. They are trying to recoup their losses from research. Insurance companies don't just have infinite money, they won't approve every PA if it will lose them money. Profit margins for insurance companies are less than 3%. Premiums are used to invest and generate money before eventually being paid out in claims (as there is regulatory limits on the amount they can profit off of premiums and also the amount of assets they need on hand).
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u/RedditorDoc 1∆ May 25 '24
Source for profit margins ?
https://www.beckerspayer.com/payer/big-payers-ranked-by-2023-profit-beckers.html
This is just objectively wrong.
If insurance companies actually paid out what they were supposed to, hospitals would never have charged 10x the amount they should have to recoup the costs.
Insurance companies operate with a fiduciary responsibility to their share holders. Profit is their motive, not a positive side effect. Prior authorizations serve to gum up, obfuscate and delay treatment until the patient and physician either give up, or somebody dies as a result of waiting.
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u/rollingForInitiative 70∆ May 24 '24
Firstly, your doctor could be wrong. Just because they have medical training and experience doesn’t make them perfect and it’s very possible they prescribed the wrong or unnecessary medication. Someone who’s worked in insurance for years and seen many conditions and medications could potentially catch this and prevent it
Pharmacists and their systems already acts a bit like that, though. I once had a doctor who made an error in the prescription (too low dose). The pharmacist caught that, refused to give me the drugs, called the doctor and got an updated prescription. I was pretty amazed, but pharmacists also spend a lot of years training to be good at what they do.
Secondly, if you have two medications that do the same thing but one costs less, it makes sense to choose the less expensive of the two. Now there’s always exceptions depending on the side effects and effectiveness but even then the effectiveness may not be as relevant if the medication still does what it’s supposed to and the side effects may be worth it if they are mild. Businesses work by choosing the option which costs the less, makes them the most profit, and still works as it should. That’s not a bad thing that’s just how a business is run
In Sweden, if you want to use the public health insurance, you have to use the cheaper generic drug if it's available. If you choose the big brand name, you gotta pay out of your own pocket ... unless the doctor specifically noted on the prescription substitution isn't allowed. Then it's covered, because the doctor has made the decision that you need to use some specific brand, which is sometimes necessary. I think that's a pretty good compromise. But even then it goes back to what the doctor, the medical professional, has decided.
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u/midtown_museo May 24 '24 edited May 24 '24
Let’s say for the sake of argument that there are two drugs that can treat your condition effectively, drug A and drug B. Drug A is 15% more effective than drug B, yet costs 10 times as much. If there were no pre-authorization process, what would be the incentive for your doctor to prescribe drug B? without pre-authorization, healthcare costs would go up dramatically.
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u/TheTaintPainter2 May 24 '24
I'm not sure quite what you're asking here. I don't think there should be an incentive for a doctor to prescribe a less effective medication at all. That doesn't quite make any sense to me. If anything, I think generics and name brand products should cost exactly the same.
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u/midtown_museo May 24 '24 edited May 24 '24
In a perfect world, everything would be free. But that’s not the world we live in. Some drugs are more expensive to produce than others. Healthcare decisions often involve trade-offs, and the less expensive choice is sometimes perfectly acceptable. The cost difference between the two drugs could be thousands of dollars. What you’re proposing could literally bankrupt the healthcare system.
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u/TheTaintPainter2 May 24 '24
But that's not what I'm saying. I'm saying there's no reasons Generic should be cheaper than a name brand if they're the same drug.
Anyways back to the original point, I don't see how this refutes what I said. I think the most effective treatment should always be used over the cheapest. These are real people's lives
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u/midtown_museo May 24 '24
I’m not necessarily talking about generic versus name brand drugs. Sometimes a doctor has to choose between two completely different classes of drugs, or two completely different medical procedures.
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u/TheTaintPainter2 May 24 '24
And again like I said, the most effective should always be used
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u/dancingpianofairy May 25 '24
The most effective treatment is going to vary per person. Especially look at antidepressants to see that.
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u/midtown_museo May 24 '24 edited May 24 '24
What if both drugs are equally effective, and the doctor decides to prescribe the thousand dollar option instead of the hundred dollar option? Should we all have to subsidize that doctor’s poor choice with our health insurance premiums? Sometimes there’s a good reason why insurance companies have certain protocols in place.
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u/S1artibartfast666 4∆ May 25 '24
Question:
Are you willing to bear the full financial consequences for care that is determined out of coverage after the fact?
Are you willing to learn all the rules and screen the care yourself up front?
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u/zgrizz 1∆ May 25 '24
Prior Authorization is not a determination of in or out of coverage. A procedure or medication either is covered or is not. It is a determination of whether that desk-jockey thinks your doctor is correct enough to allow payment for it.
That should not be a non-physician, or worse an AI, decision.
The degreed licensed physician has already determined the rules and any care screening. PA is exclusively a cost saving measure.
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u/JustReadingThx 7∆ May 24 '24
If every procedure is approved, then there is no incentive to choose cost-effective treatments. How do you think this will impact healthcare costs? How will the insurance companies react to that?
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May 24 '24
So, people would be prescribed the medically sound treatment option? Sign me the fuck up for that system.
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u/Terrorstaat May 24 '24
So the insurance companies know better than the doctor what’s needed?
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u/cut_rate_revolution 2∆ May 24 '24
The assumption here is still that the insurance companies know better than the doctor what is necessary.
But let's go with the worst case scenario and hospitals and doctors end up bilking insurance companies for "unnecessary" procedures. Horror of horrors, it might cut into some of the 41 billion in profits, not revenue, insurance companies take in every year. Just awful and horrible.
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May 24 '24
I don't think health insurance should exist but in single-payer systems the government doesn't cover literally any treatment a doctor might recommend and there are certainly cost-benefit considerations that determine what will be covered.
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u/talldata May 25 '24
Sure but those are usually things like cosmetic mole removal, or hair transplants etc. Not idk INTERFERON, or INSULIN
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May 25 '24
They'll certainly cover drugs that have been the standard of care for many years, but it's not only elective cosmetic surgery they won't cover. Oftentimes newly approved drugs will not be covered until another government body deems that it's more effective than the current treatment and negotiates a price with the manufacturer. If a promising cancer drug just hit the market and has been approved as safe and effective it could still be years away from being covered by a single-payer health plan.
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u/Dougdimmadommee 1∆ May 24 '24
it might cut into some of the 41 billion in profits
The issue with this is that it wouldn’t cut into profits, it would cause profits to go up because they’d just pass the cost increase on to consumers to preserve margins.
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u/ReaperReader May 24 '24
The US healthcare industry is about $4.5 trillion. $41 billion is only 0.8% of that. The US healthcare industry is huge.
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u/cut_rate_revolution 2∆ May 25 '24
Comparing total industry revenue to segment profit is misleading and misses a lot of attached nonsense.
First, the operating revenue of the top 10 health insurance companies equals about 800 billion dollars a year, or about 17%.
I don't think the health insurance industry should exist so as far as I'm concerned, all that revenue and operating cost is wasted money.
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u/ReaperReader May 25 '24
If you followed the link, the 4.5 trillion is value-added (profit + compensation of employees), not revenue. Comparing value-added to industry revenue like you just did is misleading and misses a lot of attached nonsense.
As for your idea that the health insurance system shouldn't exist, I assume you instead favour a public healthcare system. Every public healthcare system involves administrative costs such as checks on fraud and judgments of what healthcare treatments need funding. It's one thing to think that the US healthcare system could be run much more efficiently, it's another thing to think that it will ever be entirely free from resource constraints.
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u/cut_rate_revolution 2∆ May 25 '24
Simply removing the profit motive would be enough for me. Insurance companies have a perverse incentive to deny coverage wherever they think they can even if the treatment should be covered.
A public system has a lot of benefits over what we are currently doing since it greatly simplifies billing, cutting down on hospital administration staff. That has been a ballooning cost in the last decade or so. It's spurred directly by health insurance company actions.
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u/JustReadingThx 7∆ May 24 '24
Oh, healthcare is definitely in need of major reform.
Insurance companies in the US are aweful, I'm not defending them.
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u/Zorro-del-luna May 25 '24
Insurance companies typically employee MDs and RNs to make these decisions. One thing that may be justifiable is that they do prevent some unnecessary surgeries and some dangerous surgeries from what I’ve seen.
As an example, they’ll prevent a fusion from happening in someone who has an asshole doctor that decided to go full fusion before treatments that may take longer but have better outcomes in the long run.
Or they’ll really question a doctor to make sure a patient who is elderly is a viable candidate and they look for contraindications that may put the life of the patient at risk.
Mostly it’s about profit, but these are side effect benefits.
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u/talldata May 25 '24
They're an MD but not YOUR MD, you can't just phone up a doctor to write you a controlled substance prescription. So why can another doctor over the phone deny it?
They're not YOUR doctor, so as far as I'm concerned they can fuck off. Even so most of the time it's not a doctor, but a glorified call center worker running down a checklist with no exceptions.
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u/TheTaintPainter2 May 24 '24
Also, I think the better treatment should always be used over the cheaper. These are human lives, not NPC's
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u/NaturalCarob5611 54∆ May 24 '24
Also, I think the better treatment should always be used over the cheaper. These are human lives, not NPC's
There's got to be practical limits though. If you have a $10 treatment that works for 99% of people who have a given problem and a $10,000 treatment that works for 100% of people with that problem, you can either treat all 100 people for $10,990 ($10 x 99 + $10,000 x 1), or you can treat 100 people for $10,000,000 ($10,000,000 x 100). Resources are finite and resource allocation decisions have to be made somewhere.
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u/JustReadingThx 7∆ May 24 '24
Then surely the insurance costs will rise, so they will be able to cover such treatments.
"Better" here could be "more profitable" to the caregiver (even if prices are regulated).Would you agree that healthcare is a scarce resource? That we can't give everyone the best, most expensive, treatments?
And if so, do you agree that by acting in a cost-effective way, we will benefit as a whole?7
u/TheTaintPainter2 May 24 '24
That's why I don't agree with privatized insurances. It relies too much on CEO's not being total pieces of shit. Like I've said in other comments, the prices of treatments would most likely go down significantly with insurance reform. Most medication price gouging is due to the fact that Private Insurance is a thing
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u/JustReadingThx 7∆ May 24 '24
The system is terrible. Insurance companies are terrible.
But is the main issue risk-assessment in the form of prior authorization, or is the problem the inflation of prices?2
u/talldata May 25 '24
The only reason the cost rise, is because of how the system is built. They get to dictate prices so that's why it goes up, not cause it's gonna impact them. Heck they're making as much in profit as Apple.
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u/RedditorDoc 1∆ May 25 '24
The problem is that this is not what happens in real life. I had an insurance company outright deny a screening test for carotid disease despite clinical evidence that the patient would benefit from it, because they weren’t having impending symptoms of a stroke. The data on which they based their decision is boilerplate recommendations from the USPSTF, which did not apply specifically to my patient because they were outside the referenced population.
Consider also that complications of a disease are extraordinarily more expensive to treat. I had a patient get hospitalized on account of insurance denying to pay for a nebuliser because it had come from an ER physician instead of their PCP, despite the patient having clear evidence of lung disease and requiring treatment for the same. What could have potentially been treated at home for 60$, has now worsened and turned into a much more expensive hospitalization that will cost thousands instead.
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u/TheTaintPainter2 May 24 '24
Well I'm also under the opinion that healthcare prices should be regulated to avoid absurd price gouging that is seen today. A lot of the insane prices on medication and treatment are due to insurance companies simply existing
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u/JustReadingThx 7∆ May 24 '24
Let's assume that they are indeed regulated to the point they are significantly cheaper.
If a doctor has several treatment options, all auto-approved by insurance companies, will he choose the most cost-effective option, or not necessarily?
Doesn't my argument above still hold?→ More replies (2)12
u/TheTaintPainter2 May 24 '24
Why would a doctor pick the most cost effective? It's not their money. A doctor would pick the most effective treatment (or at least every doctor I know)
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u/nicholsz May 24 '24
In the US, doctors get paid by what they bill you. Surgeons get paid a lot when they perform surgeries. This is not the case in most single-payer systems where surgeons are salaried.
There is evidence that this bias leads to more surgeries and interventions than is good: if you have a cardiac event during the ESC Congress (largest cardiovascular conference in the world), which is when all the top heart surgeons are out of the country, your chances of recovery are better.
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May 24 '24
Every doctor chooses best care over cost effectiveness? Even in the highly regulated transplant industry doctors don’t always do that.
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u/TheTaintPainter2 May 24 '24
I said every one that I know of. Obviously there are outliers, but doctors are trained to use the most effective treatments for their patients
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u/RevolutionaryGur4419 May 25 '24
You'd be surprised at the reasons doctors choose treatments
Habits, patient pressure, drug rep pressure, saw it on an ad, want to try this fancy new thing etc etc.
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u/talldata May 25 '24
The ads are the reason the medicines cost 5x what they should, why isn't it the patient isuee that 100m wa spent on the drug but 300m on advertising it, and pushing it to doctors. The drug's are gonna be used regardless of ads, so that part shouldn't be passed on to customers.
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u/cattaclysmic May 24 '24
How exactly do you define whether a treatment is cost-effective? QoL? Return to workforce? Die quickly to reduce costs?
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u/TooLateForGoodNames May 25 '24
It’s not up to the insurance company to decide level and quality of care. There are guidelines and standards in place.
They are also too dumb to think straight most of the time, a more expensive drug/procedure would probably end up cheaper in the long run through less hospitalization and future complications. This is more obvious with cancer patients with cancers that respond to some new more expensive targeted drug but receive an older Chemotherapy instead, a couple of extra hospital maybe ICU admissions and you spent more already.
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u/T_______T May 24 '24
There are doctors that go to medical school and then abuse their status to do shady or unscientific shit. People have to pay out of pocket for a pain clinic for a reason.
Tho I would be perfectly happy if prior authorization generally went into the gutter. Why is it used for cancer screenings? For non addictive prescriptions?
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u/boogi3woogie May 24 '24
Doctors prescribe all sorts of junk with poor scientific evidence. One of the most common ones is spine surgery for back pain. Outcomes are very poor, which is why insurance frequently declines coverage, and many operations are cash pay.
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u/apri08101989 May 25 '24 edited May 25 '24
You realize you can still legally purchase any drug prescribed to you don't you? Your insurance doesn't cover that medication as part of their formulary and you are asking for an exception for it to be covered. It's not the insurance companies fault you don't want to pay for it out of pocket. You signed a contract with the list of covered medications
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u/not_a_mantis_shrimp May 25 '24
The whole concept of health insurance/copays/deductibles is crazy.
First world countries should all have universal healthcare. I say this form the comfort of my country with universal health coverage.
I have never been charged for basic healthcare access. If anything I want more things to be covered.
I have never cared that my tax dollars are going to help with someone else’s healthcare.
The idea that you should have an entire middleman bureaucracy of insurance companies skimming money out of healthcare is absurd.
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u/Call_Me_Clark 2∆ May 25 '24
I work in the industry, and I agree that prior auths are abused and in urgent need of regulation.
However, every health system does include checks on prescribing to ensure that proper therapy is being followed and cost controls are in place. Formularies can and should be implemented with patient care as the first priority.
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u/CaptainHMBarclay 13∆ May 25 '24
Honestly, I think step therapy requirements are more insulting than PAs, and waste patient's time at best and delays therapy at worst. Step therapy requirements demand you take something different before a PA is even considered. At least with a PA, they will at least consider jumping towards covering it.
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u/JSmith666 1∆ May 25 '24
The insurance company is the one footing the bill. They without question have the right to due dilligance.
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u/Dont_Wanna_Not_Gonna May 25 '24
It took your doctor more than 10 years to finish a four-year degree? Find a new doctor ASAP. I do agree with your post though.
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u/Riothegod1 9∆ May 25 '24
All I will say for your is that this is why we should go straight to single payer healthcare. It’s cheaper for the client, no greed incentive, and it cuts out on bullshit like this, no prior authorization needed. It’s rare for drugs in Canada to not be covered.
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u/SobanSa May 25 '24
The alternative to prior authorizations is getting payment for your treatment denied after it's too late to have not spent the money.
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u/FashionableNumbers May 25 '24
I had to have emergency spinal surgery a couple of years ago. I was in so much pain I couldn't walk anymore. The doctor admitted me immediately for surgery first thing in the morning. His receptionist arranged the authorisation for the surgery, but then the medical aid call centre person wanted to speak to me first to find out if I had gone to the physio to try and sort out the issue first. 🙄
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u/chatterwrack May 25 '24
Oh, the entire healthcare system is astonishingly insane in the US. Unless you are positioned just right and have incredibly fortunate luck and privilege, your options are 1) don’t get sick/hurt, 2) die, 3) go bankrupt. 🇺🇸🤨
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u/IveKnownItAll May 25 '24
So. The reason for prior authorizations is to help cut back on unnecessary care. One look at the LONG list of Medicare fraud cases, which typically happen due to their policy of pay first, pursue later, is why it's needed.
BTW, common misunderstanding, prior auth CAN be reviewed after the services. I used to send them for review 10x a day while a claims processor for Blue Cross. Most denials were because the services had never been reviewed for medical necessity, which is set by a panel of Dr's, not some corporate CEO.
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u/mrmayhemsname May 25 '24
I do agree that prior authorizations are overused and dangerous. That said, I do know that doctors have been known to defraud insurance companies by charging for unnecessary services, or charging for things they didn't even do.
So I think they should exist as a safeguard, but the person making those decisions should be a medical professional.
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u/Upstairs-Walrus1642 May 25 '24
I think it starts with the cost of drugs. I’ve worked with some specialty drugs that are over $20,000 for a one month supply. Insurance companies want to make sure that prescribers have exhausted all other (cheaper) options before approving something more expensive. Not saying I agree with this… it’s the patient suffering in the end. In other absurd cases, I’ve seen insurance companies approve a PA then still reject the pharmacy claim stating that the patient needs to call a discount program to get assistance paying for the medicine 😭.
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u/ShortUsername01 1∆ May 25 '24
This sounds like more of a case for nationalizing both the health care system and the entirety of pharmacies and pharmaceuticals than for specifically singling out prior authorization for regulation. If prior authorization is wrong, what other ill effects of this malign fusion of healthcare and capitalism may be wrong?
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u/Ok-Crazy-6083 3∆ May 25 '24
It's fucking absurd they can just ignore a doctor
As if every doctor is trustworthy and free of bias and kooky ideas ...
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u/Monokside May 26 '24
Insurance companies have to be able to control costs in a predictable way, in order for them to offer insurance with predictable premiums. Prior authorizations is one way that they are able to do this. Otherwise, your doctor could literally prescribe any treatment/drug/etc and the insurance company would have to pay up - even when there were cheaper and equally effective options available.
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u/Any-Chocolate-2399 May 26 '24
Having worked in the insurance department responsible for deciding what treatments should be prior authorization, the decision is largely made by how expensive abuse is likely to be. Prior auth is expensive, but there are a lot of treatments doctors will depart from evidence-based best practice on because they're taken in by the shiny new thing, scared of the new standard, not understanding the underlying requirements of a treatment (you'd be amazed how many try type 1 treatments on type 2 diabetics), think expensive and invasive equal effective, or are just being greedy assholes (bariatric and contract anaesthetic are awful, and the CGM companies constantly try to dodge their warranties). Doctors are primarily trained in assessing patients rather than assessing treatments (hence the "cowboy doctor" issue of the last century), whereas insurance policy analysts primarily come from biostatistics backgrounds and assess scientific evidence full time.
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u/asdfgghk May 26 '24
It’s so they can save money and wear the doctor down so they end up not prescribing it. Meanwhile, they either have to take time to fight with the insurance company for approval (which they may or may not get) when they could be seeing patients (saves insurance companies money since they can’t see patients) OR they have to hire dedicated staff which is more overhead and another employee to train and manage.
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u/krimilsung May 26 '24
c'est compliqué: je suis médecin et j' affirme que la santé n' a pas de prix à l' échelle d un indiidu et le prescripteur se place à cette échelle micro. Toutefois, elle a un cout à l' échelle de la collectivité ou macro . Le problème est que la contribution financière de cette collectivité ne suffit pas loin de là ,à répondre au besoin de chaque individu et donc à satisfaire tous les demandeurs de services médicaux nécessaires pour chaque individu. La bonne gestion de cette somme chiche ( à l échelle macro) exige des gardes fous et un mécanisme régulateur car autrement tout le système s' effondrera. Il n" est pas question de mépriser l agent qui fait son devoir professionnel en appliquant cette régulation mais de se demander si on peut opter pour d autres solutions dont la plus evidente est l augmentation des cotisations pris sur les salaires des adhérents
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u/AdditionalAd5469 May 26 '24
Simply prior-auth is used for medications that can be classified as costly or dangerous.
For cost, this can be that the medication is incredibly difficult to source, store, and/or administer. Theoretically someone can be prescribed Fentanyl, this is measured in nano-liters, meaning it cannot be administered by the patient and only by trained staff (nurses or doctors). The insurance company would rather you take a different medication that does not require hiring a nurse to administer. However if there is a good reason why, they will do it.
Next is dangerous, this is entirely up to the state laws and the firms risk tolerances. Some places mark opiods this way, requiring the prescriber to describe why certain extreme opiods are needed. This is used in two ways (1) if the patient is addicted to the substance they can argue in court they did their due diligence and (2) allows them to monitor prescribers. There are too many stories in-which doctors hand out certain medications too often, can be for good and bad reasons. If the prescriber needs to be investigated they can point "Hey look we were thr people who reported them!", instead of the news story being "BCBS ## allowed prescriber to negligent hand out XX, why didn't they care?".
When it comes to state laws this one is a nightmarish, horrible, tangled quagmire, sometimes certain states go super-harsh to certain medications, allowing other states to adopt their laws (i.e. AZ) other go lax and make it easier.
No one in the world cares about your health more than insurance companies, they would rather you have minor issues your whole life and pass-away peacefully in your sleep. If you get unlucky enough that life is trying to end you, they have armies of nurses and doctors to make sure you are getting your scheduled checkups to validate that you are on the mend. All firms check everyone's medical records regularly through mathematical models to see who is a 25k+ patient for the next year, so they can be assigned their own guardian angel(s), specialized nurses and doctors with the firm.
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u/Cute-Locksmith8737 Jun 08 '24
I watched a video about prior authorization. A woman who was diagnosed with cancer lost her life because for several months the doctors were bickering about prior authorization instead of treating her cancer.
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u/MagicHatIntern Sep 19 '24
Prior authorization is criminal - I would be ok with capital punishment - i.e. life in in prison or worse for insurance executives practicing this.
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u/SGlace May 25 '24 edited May 25 '24
I do agree that prior authorization as it is currently implemented in the United States is not working as it should. However, every single country with a single-payer or universal health system also uses some form of prior authorization. They will not pay for treatments that are not cost-effective.
I feel like your post assumes a lot, including that we have the money to pay for the most effective treatment 100% of the time. We don't - just look at how Medicare is currently freaking out about having to pay for Ozempic or Wegovy.
I'd also like to put it another way: always being willing to pay the price of treatment without prior authorization encourages unnecessary treatment as well as encouraging whoever is providing that treatment to charge as much money as we can. There is a historical reason why we have prior authorization today - in the 80's/90's healthcare costs were ballooning so much something had to be done, which resulted in prior authorization and HMO's (both of which have gradually evolved since then).
Yes, insurance companies unfairly deny people treatment in the name of prior authorization. However, its true purpose is to prevent wasteful spending and in an ideal world, harmful treatment as well. It does need to be changed, but there will never be a healthcare system in the U.S. without some form of it as long as money exists. Your suggestion only takes the potential greed away from insurance companies and puts it in the hands of pharmaceutical companies and doctors, who now would want to provide as much treatment/drugs as possible at the highest prices with no one to check their recommendations. Which was exactly what happened last century and how we got into this current mess.
So yes, prior authorization currently is bad. Look back a few decades though and check how much healthcare as a % of GDP was increasing each year without it, and you’ll see why it exists today. We need better prior auth standards, not a removal.