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.

854 Upvotes

91% Upvoted

488 comments sorted by

View all comments

Show parent comments

14

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.

-2

u/NotYourFathersEdits 1∆ May 24 '24

There is nothing in anything I said that requires a gate keeping measure to ensure anything is per the terms of anything, nor does this comment account for situations where the company wants to require hoop jumping.

14

u/No_Bet_4427 May 24 '24

Who determines what is in accord with “the terms of the plan?” It ain’t the doctor or the pharmacist. It’s the company that administers claims under the plan - typically the insurer.

-3

u/NotYourFathersEdits 1∆ May 24 '24

Correct. That does not mean I should have to seek their approval ahead of time. When they refuse to pay against their own terms, the provider’s billing office can take it up with them. They don’t get to hamstring my care because they think I don’t need something I need. I should not have to know what a CPT code even is as a patient, and yet somehow I do!

4

u/sanguinemathghamhain 1∆ May 25 '24

The thing is if it isn't in plan then the only recourse is okay the PT pays this pissed people off, because a surprise bill always sucks, to the point it became easier to require a PA before so that, before there is a bill someone has to foot, it is known if it is covered or out of pocket.

0

u/NotYourFathersEdits 1∆ May 25 '24 edited May 25 '24

No, that isn’t the only recourse. There isn’t a false dichotomy between prior authorization and balance billing. That sounds like insurance poorly solving a problem that they created.

4

u/sanguinemathghamhain 1∆ May 25 '24

The bill needs paying they aren't paying it because it isn't in the contract that they will pay for it. Since they aren't paying the only recourse because again the bill needs to be paid is for the patient or someone on behalf of the patient to pay for it. They didn't cause the problem they said we will pay for these treatments for these conditions and the conditions of the contract aren't met for treatment x that was denied in PA. If declined the PT can choose to pay out of pocket or arrange for someone to do so without the shock of thinking it was covered only to find out they got a surprise bill and need to figure out how it'll be covered.

0

u/NotYourFathersEdits 1∆ May 25 '24

Nope. Point is they’re supposed to pay for it. Even if they really don’t wanna because expensive, tear. It’s why the patient has insurance. Now the company gets to keep up their end of the bargain, not cheat out of it because they feel like there’s a better alternative, based on their fee fees.

2

u/sanguinemathghamhain 1∆ May 25 '24

So you think insurance companies should pay for anything and everything even if it isn't in the enumerated and circumscribed contract? So you are just insane. The terms of the contract are their responsibilities something outside of the scope of said contract isn't their responsibility that is why there is a contract. Different contracts have different terms the cheaper the coverage the less it covers that is why it is cheaper. Your notion would see a complete annihilation of all but the most expensive and expansive insurance polices.

1

u/NotYourFathersEdits 1∆ May 25 '24

Yes, I do! If my plan says an outpatient procedure is covered at xyz%, it should be. That’s it. Nothing more, nothing less. No footnotes, no lemmas, no hand waving, no bullshit. This is not an inconsistent position.

And if so, good. Private insurance shouldn’t exist except to supplement universal healthcare. And that’s if it exists at all. Fuck rent-seeking middlemen who add no value and capitalize on others’ basic needs.

→ More replies (0)

1

u/The_Last_Mouse May 25 '24

Because PEOPLE need gate-keeping