Insurance company abuse puts more patients’ care out of reach

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Health insurance companies have long forced patients through frustrating administrative steps to get the care they need, but lately their typical convoluted tactics have turned into abusive practices that threaten patients’ health and well-being. . When there was another disheartening rise in Covid-19 cases, President Joe Biden ordered commercial insurers to reimburse consumers for the cost of rapid home tests – a welcome and clearly necessary policy given the prices of these tests and how they help keep us safe and secure. each other.

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

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

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

Even before the latest Covid-19 testing debacle, insurance companies erected a series of aggravating hurdles intended to discourage patients and doctors from battling the company for coverage. For example, prior authorization is a popular insurance practice that allows the insurer to delay or deny treatments and services prescribed by a patient’s doctor. By questioning the treatments doctors develop to meet the unique clinical needs of their patients, insurance companies hope to delay payment for necessary procedures. According to the American Medical Association, 93% of physicians report delays in care due to prior authorization, and 34% of physicians report that prior authorization resulted in a serious adverse event for a patient in their care.

You don’t have to search long to find many examples of prior authorization abuse. In January, a veteran health reporter chronicled his frustrating experience getting the insulin he had been taking for more than 10 years. With just 17 days’ supply of the life-saving drug, Bram Sable-Smith was suddenly hit with prior authorization requirements that prevented his doctors and pharmacists from dropping his next prescription. After making 20 rushed phone calls himself — not to mention the efforts of his healthcare team — he was finally able to get insurance company approval for insulin just hours before his supply ran out. For a seasoned journalist who fully understands our hyper-complex healthcare system, this process was almost too much to handle. What should the average patient do?

When prior authorization was designed, it was intended to reduce costly, experimental and unnecessary treatments and procedures. But increasingly, the nation’s largest insurers are using prior authorization to delay or deny routine and medically necessary care. For example, Aetna began requiring prior authorization for everything cataract surgeries – one of the most common and effective procedures in all of medicine – in July 2021. As a result, thousands of patients have had their surgeries canceled or postponed, even as cataracts increase the risk of falls , car accidents and, as a recently published study sheds light on dementia. According to ophthalmologists, Aetna refused to provide any data to justify this rationing of care.

The misuse of prior authorization by insurers creates health risks for patients and contributes to increased downstream costs for both beneficiaries and the health care system as a whole.

Fortunately, a bipartisan group of lawmakers in Congress shares these concerns and is working to curb the worst abuses in insurance. The Improving Timely Access to Care for Seniors Act (HR3173/S.3018) is a popular bill gaining support in Washington. It would protect the nation’s seniors from unnecessary delay or denial of their care by simplifying the pre-authorization process and holding insurance companies accountable for disruptions and delays. While the legislation would only apply to Medicare Advantage (MA) plans, it represents a major first step in the fight against insurer overspending. With MA enrollment on the rise and Aetna’s parent company, CVS Health, promising to “prioritize our high-growth markets” like Medicare Advantage, it makes sense that Congress would first draw a line in sand.

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

Photo: Piotrekswat, Getty Images

This article has been updated to reflect the results of a recently published survey.

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