Posted on 09/17/2023 5:44:33 PM PDT by ConservativeMind
…Prior authorization is a common cost-cutting tool used by health insurers that requires patients and doctors to secure approval before moving forward with many tests, procedures, and prescription medications. Insurers say the process helps them control costs by preventing medically unnecessary care…
That's why desperate patients like Nix—and even some physicians—say they have turned to publicly shaming insurance companies on social media to get tests, drugs, and treatments approved…
But some patient advocates and health policy experts question whether insurers are using prior authorization as "a possible loophole" to this prohibition, as a way of denying care to patients with the highest health care costs, explained Kaye Pestaina, a KFF vice president.
"They take in premiums and don't pay claims. That's how they make money," said Linda Peeno, a health care consultant and retired Kentucky physician who was employed as a medical reviewer by Humana in the 1980s and later became a whistleblower. "They just delay and delay and delay until you die. And you're absolutely helpless as a patient."
Customers are increasingly using social media to air their complaints across all industries, and companies are paying attention. Nearly two-thirds of complainants reported receiving some sort of response to their online post, according to the 2023 "National Consumer Rage Survey.”
…Stallman, who is insured through her employer, said she and her husband were prepared to pay out of pocket if Blue Cross of Idaho didn't reverse the denial for the drug Zoey needed.
Bret Rumbeck, a spokesperson for the insurer, said Zoey's medication was approved on July 14 after the company consulted an outside specialist and obtained more information from Zoey's doctor…
Nix said an "escalation specialist" from the insurance company reached out after she posted her complaints on social media, but the specialist couldn't help…
(Excerpt) Read more at medicalxpress.com ...
Doctors are also seeing previously approve treatment later disapproved by an insurance company and a demand for payment to be returned.
The flip side of this is that there’s a reason why the only medical procedures that decline in cost over time have been the ones that insurers don’t cover. It’s amazing how economical medical procedures get when they are discretionary and people pay for them out of their own pockets. I’ll cite laser eye surgery and cosmetic surgery as two examples of this.
wow..i wasnt aware they did this.
We just ran into a similar case.
Knee Surgeon Doctor’s staff tells us Surgery Center does not accept our Devoted PPO Medicare Plan. Schedules us at local hospital for surgery with higher co-pay.
Devoted says the facility is in-network.
Seems like Doctor is trying to force us (some patients) to use hospital as there is higher demand for out patient places.
But Doctor’s office staff lying to us to achieve a better schedule for the Doctor is unethical.
This is one of dozens of reasons many insurance companies have less-than-ideal reputations. It’s not just health insurance.
My auto insurance company took 4 months AFTER my stolen truck was recovered to make a decision whether to repair it or just pay me out. The truck’s value dropped by near half during their dilly-dallying. The worst part is that there had been as much maintenance work done on the truck in the previous year as they paid out for the total loss. In fact, three weeks before the theft, the whole suspension had just been redone to factory specs, and the steering box had just been replaced, with a new turbo housing as well. That alone had cost 2/3 of what was paid by the insurance company for the loss. It also had only 8K miles on a new set of Toyo M-55’s all round.
I LOATHE all insurance companies. They’re more than happy to take your premiums, but heaven forbid you actually have a claim, because they will move heaven and earth to avoid paying out one thin dime.
Yes insurance does deny care, humana and united Healthcare. I heard the phone calls for reviews.
The US “insurance system” will not survive 5 years. Medical services economics are in a death spiral.
I am a humorous example of this prior auth stupidity. My doctor has prescribed a medicine for me that is on a controlled substance list. The max prescription is a 30 day supply. My insurance requires mail order after three fills. But they also would not approve the 30 fill under this prior auth crap. And they insisted on faxing the forms to the doctor instead of allowing email or some web page.
This drug costs about a penny a pill. And they were refusing to approve a 30 day fill. But they were happy to allow a seven day supply.
So for the last four months I have had to go to the mail-order pharmacy’s website every week to “refill” my seven day supply so they could mail me seven pills and charge me nine cents. Their stupid slow-marching of this prior auth is costing them the price of postage minus the nine cents they have been billing me.
They finally came to their senses last week and approved the prior auth. Now they get to bill me 39 cents for 30 pills.
If they pull this crap over pennies, it is not a surprise they also pull this crap over something costing thousands.
You bet. The insurance biz is a racket. The house odds totally favors big insurance. Same reason why they hire investigators, most of which are retired cops, to minimize and or eliminate potential losses/claims.
They don’t give a crap about our lives or health, only about their profits, which in more and more cases will be higher with us dead, as we are cost centers.
I think this is a First Amendment issue.
So just have at it. (And none of that “pistols at dawn” nonsense.)
You are so right. This falls into the "no solutions, only tradeoffs" principle (Thomas Sowell). Our current system sucks, but I'm afraid people seeking a perfect "solution" will bring about something even worse.
Neither was I, talk about thief of services.
I’m not sure what state you live in, but typically the first fill or two are one week “trial periods.” If you need it after that, typically they cover it 30 days at a time. Cor CII controlled substances, 30 days is max. I’m having this problem with one of mine, as it’s on backorder. Joy.
Prior authorizations might be necessary in that case. I also don’t trust mail order; stuff gets stolen that way.
Yes, for me the first four seven-day fills were the trial, and were allowed to be filled at a local pharmacy. After that they force us to use mail order for “maintenance” meds. And it was another three months of seven-day mail-order fills, each one notated that it was pending prior auth. I called them several times early on, but it was clear they were going to just pull my chain, so I just kept up with the weekly order.
I see the problem being that people with a BA in accounting are making medical decisions.
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