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New Biden rule cracks down on insurers’ use of prior authorization (thehill.com)
submitted 9 months ago by MicroWave@lemmy.world to c/news@lemmy.world
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A new Biden administration rule released Wednesday aims to streamline the prior authorization process used by insurers to approve medical procedures and treatments.

Prior authorization is a common tool used by insurers but much maligned by doctors and patients, who say it’s often used to deny doctor-recommended care.

Under the final rule from the Centers for Medicare and Medicaid Services, health insurers participating in Medicare Advantage, Medicaid or the ObamaCare exchanges will need to respond to expedited prior authorization requests within 72 hours, and standard requests within seven calendar days.

The rule requires all impacted payers to include a specific reason for denying a prior authorization request. They will also be required to publicly report prior authorization metrics.

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[-] Froyn@kbin.social 63 points 9 months ago

LPT: If your doctor firmly believes that you require X treatment/medication/etc. Have them use the specific term "medically necessary". If your insurer kicks it back with that phrasing attached, contact them. Ask for the medical license number of the doctor who indicated that it was not medically necessary. Push for this information (they won't have it) and continue the line of "Someone on your end is making a medical decision against my doctors orders. I require their credentials so I can confirm they are a) qualified to make medical decisions, and b) have a higher education that my doctor possesses."

[-] otp@sh.itjust.works 17 points 9 months ago

This reads like a summary of a chapter in a dystopian novel

[-] athos77@kbin.social 6 points 9 months ago

It reads like sovereign citizen advice.

[-] ChillPenguin@lemmy.world 7 points 9 months ago

Ffs, is this truly where we are at? Fuck me...

[-] JustZ@lemmy.world 1 points 9 months ago

Nurses usually make these calls, as I understand.

[-] Fedizen@lemmy.world 10 points 9 months ago* (last edited 9 months ago)

Prescription: Your doctor thinks you need a medication

Prior Authorization: Your insurance doesn't want pay for the medication and wants your doctor to affirm that he wrote a prescription

[-] The_Picard_Maneuver@startrek.website 9 points 9 months ago

This is a good step in the right direction, but I'd like to see it applied to commercial plans as well. Prior authorization is everything they're saying it is and worse.

[-] breadsmasher@lemmy.world 1 points 9 months ago

the madness that is US “healthcare” never ceases to amaze me.

Know what happens when a doctor recommends me a treatment? I get that treatment.

I don’t have to hope an insurance company will “approve” of me getting that treatment. I don’t have to worry about paying for it.

Anyone still defending this system needs psychological help. Which would be denied by the insurance company. And cost 10000s out of pocket

[-] Witchfire@lemmy.world 1 points 9 months ago* (last edited 9 months ago)

Anyone still defending this system needs psychological help. Which would be denied by the insurance company. And cost 10000s out of pocket

Approximately half the country supports it because it hurts people they don't like, and they're about to elect a literal dictator. Please send help

[-] csm10495@sh.itjust.works 0 points 9 months ago

How about a similar rule that puts the provider on the hook for getting authorization for what they do?

Like I know the system is fucked, but I don't want my doctor having me go somewhere to find out I get a $500 bill. Make them get authorization and if it fails tell me the cost before the appointment gets made.

If I have to spit in a tube again to get a $500 bill, I'll call and threaten Natera again till they drop the bill. Bastards.

[-] Cowlitz@lemmy.world 1 points 9 months ago

They already do for big services. Thats why its called a preauthorization. It just doesn't work well in emergencies and they dont do it for shit like routine blood draws. Ive had them tell me I could get a CT now and hope they approve it or take my chances. There is still incentive for the provider to fight the battle because patients getting big bills often don't pay them at all (it helps if you tell them though, they are busy and not necessarily keyed into every patients bill status).

[-] Drusas@kbin.social 0 points 9 months ago

That would slow medical care down dramatically.

[-] csm10495@sh.itjust.works 1 points 9 months ago

But why? This should be automated based on my coverage plan.

[-] Drusas@kbin.social 1 points 9 months ago

Because it's not an automated process to get a procedure authorized.

[-] csm10495@sh.itjust.works 1 points 9 months ago

Make it automated.

[-] 4am@lemm.ee -4 points 9 months ago

Let’s not forget why Prior Authorization exists - shitty doctors who get kickbacks from labs or imaging facilities (or who own them) sending patients there unnecessarily in order to embezzle unecessary payments from Medicare and Medicaid (or even commercial) plans, draining risk pools for their own gain.

There are no good guys in America.

[-] Chetzemoka@startrek.website 4 points 9 months ago

That is already illegal. Prior auth was not a necessary intervention for this problem.

[-] mosiacmango@lemm.ee 3 points 9 months ago* (last edited 9 months ago)

So instead we have giant, mega corp insurance companie "non-profits" designing "AI" systems that auto deny 90% of all medical treatments and fight tooth and nail against the other 10%. All so they can drain money from patients and the goverment, injurying or directly killing milllions of americans every year for their own gain.

Neat fix.

[-] Cowlitz@lemmy.world 1 points 9 months ago* (last edited 9 months ago)

Whats funny is you cite Medicare fraud. Medicare has a very short list of things they require preauths for. They are the easiest to work with. They do audits and if they spot any issues will take back all of the money. People are genuinely scared of that happening as it can be a lot at once if we did something wrong for a while.

this post was submitted on 17 Jan 2024
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