When visiting a doctor’s office, seeking care for an ailment or injury, patients (AKA you and me) are usually subject to a common anxiety: will my insurance cover this? A lot of the time the answer is, essentially, yes. After all, a medically necessary procedure that falls well within the confines of an insurance plan’s stated coverage has been prescribed by your doctor.
Here patients concern themselves with details about meeting their insurance deductible, making copays, or scheduling a long-awaited surgery and looking forward to better health and function. What patients often don’t see, however, is all the effort and expense taken on by the medical practitioner’s staff in order to get to “yes” — specifically, securing the vaunted “pre-authorization” from the insurer agreeing that they will indeed compensate the provider for the covered care.
These days, pre-authorizations are basically required for everything.
One might think authorization for the vast majority of prescribed care options, when compared to listed coverage areas under an insurance plan, are expeditiously resolved. Only the obscure, fringe scenarios landing on the edge of medical necessity or your particular plan details would require a real struggle to obtain pre-authorization, right?
Unfortunately, no; the medical providers in your community are likely employing extra staff every day of the week who are wholly dedicated to convincing the insurer to authorize even the most slam-dunk, right-down-the-middle, painfully obvious coverage items.
These administrative personnel are paid to navigate the bureaucratic insurance maze looking for that “yes” the patient desperately needs to hear.
Sometimes the pre-authorization can be obtained via a web portal while you, the patient, are still in the office. Eureka! But often times it’s not that easy. The process requires your local doctor’s office to employ the additional personnel to humbly ask for permission from the insurer to provide appropriate care for you that falls squarely in the coverage area, often spending the day on hold waiting to talk with a representative. They may withhold authorization for a day or two, requiring the patient to come back for another appointment.
(Even though these struggles are mainly with the private carriers, these are the same companies we have entrusted to manage Medicare Advantage plans and all of the [expanded] North Carolina Medicaid program.)
It wasn’t always this way.
Initially, insurers only demanded pre-authorization assurances for relatively expensive care, like a major surgery, or an MRI test. This makes pretty good sense from the insurer’s standpoint; make doubly sure the expensive care is necessary before covering the cost so as to ward off unnecessary payouts and over-served care that inevitably leads to inflated premiums and costs for everyone.
Such logic is similar to that which originally spurred Certificate of Need laws. And like CON laws, the unintended consequences tend to lead in a direction opposite of those intended.
Imagine a situation in which you’ve broken your ankle. The doctor determines the injury is best treated with a brace. But there’s a problem — they can’t get authorization, just yet. As a consequence, they put you in a cast until such time as the brace is approved, and, when it is, you go back to have the cast removed and receive the originally prescribed brace.
Two-times the visits; two-times taking off work; and two-times the time and expense spent by doctors and staff to provide the one best medical solution (almost) everyone agreed on at the outset. It’s not hard to see how this would increase costs, and such scenarios occur frequently across the state every week.
Further, as one orthopedic surgeon practicing in North Carolina exclaimed to me while discussing the subject, one particular insurer “decided a couple of months ago that robotic surgery is experimental and therefore not covered.”
“We have been doing robotic joint replacements for 12 years, and it is becoming the standard of care in many places,” he added, mentioning that many younger surgeons now get trained on such procedures as part of their official surgical residencies. The repair and recovery results are simply superior due to the precision of robotic surgery tools.
Policy Solution?
During the 2023-2024 legislative session, two members of the NC House — Reps. Dr. Kristin Baker, R-Cabarrus (psychiatry); and Dr. Timothy Reeder, R-Pitt (emergency medicine) — spearheaded legislation aimed at reining in the prior-authorization process.
Endorsed by the NC Medical Society, the bill sought to bring some accountability by requiring insurers to talk with a clinician before refusing to pay for prescribed medical care, if medical necessity is being questioned, or setting time limits for reviews based on medical care level and decision making, among other requirements. The bill passed the House but died in the Senate.
Reviving such legislation during the long session would be commendable, but in our age of data analytics, more can be done to alleviate what the NC Medical Society called an “overused and burdensome” process.
Insurers keep detailed data on physicians and clinical practitioners with whom they do business. They know how many procedures, prescriptions, physical-therapy sessions a practitioner has prescribed. They know how many get authorized and denied, and they know whether those care prescriptions resulted in positive or negative outcomes.
As such, insurers could be required to examine that data in order to determine which doctors and practices are known to make appropriate decisions at an extremely high rate. A bill may stipulate that any practitioner with a designated amount of practice experience shall be issued a blanket pre-authorization from insurers if they exceed a certain threshold for historical authorizations.
The data could be examined annually, making sure each provider is being a good steward of medical financial resources while at the same time removing the expensive authorization fight medical practices endure daily to get patients the care they deserve.
A great many important items will be given focus during this year’s legislative session. Considering that North Carolinians pay more for healthcare than anyone else in the nation (!), items like CON repeal/reform and blanket pre-authorization legislation should be among them.