In a recent visit to the emergency room (side note: one of its "frequent flyers" is a wanna-be singer, dabbling in opera it sounded like), it was brought to my attention that while most of the hospital was in-network, the particular division of doctors to which I needed access was not. It was a Saturday night. The insurance company was closed. And the dreaded phrase came up regarding transfer to another in-network hospital when it became clear that a hospital admission would be necessary: "insurance preauthorization required."
It turns out, despite the fact that peoples' propensity to get sick is not exclusive to insurance company business hours, insurance preauthorization often is required for the transfer to another hospital facility, or for certain procedures to take place. This can result in unnecessary delays in obtaining needed care, or being transferred to less reputable facilities that do not carry certain restrictions.
The Department of Health and Human Services defines insurance preauthorization as follows: "A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost." Such requirements can in some cases lead to extensive persuasion by doctors to insurance companies (that is, those who are not medical professionals but on the business end of the deal) that certain procedures, tests, transfers, are medically necessary. Issues of preauthorizations absorbed in 2006 an average of 1.1 hours per week from primary care providers, 13.1 hours per week of primary care nursing staffs, and 5.6 hours per week of primary care clerical staff. While insurance companies are barred from imposing prior authorization rules in the context of emergency care, some issues regarding interfacility transfers still apply, and should it become clear that a battery of tests must be ordered in the near future, a patient nervous about an impending diagnosis and treatment may have a barrage of insurance inquiries awaiting them first.
The fact is, this is just one of many ways in which we have nominally worked to expand health care insurance coverage while simultaneously making it profoundly difficult for people to actually utilize those benefits. Whether it is a large deductible that one must meet before benefits kick in, a large out-of-pocket maximum such that expenses can continue to aggregate, or a large coinsurance that can lead one to such conditions as asking their doctor to run fewer or less expensive tests, we often find ourselves crafting policies that perhaps work well enough for those wealthy enough to afford the out-of-pocket costs or poor enough to obtain government-sponsored insurance and credits, but with the middle class continuing to get squeezed. The matter of insurance preauthorization is in fact an equalizing force in that it is not about dollar amounts but rather red tape, navigating a complex system that is all the more challenging when medically compromised and potentially from a vulnerable population. And while parity laws are meant to ensure that medical and behavioral health are treated equally with respect to benefits, such laws are notoriously poorly enforced, with "medical necessity" looked upon with greater scrutiny in the behavioral health context, adding an additional barrier to a category of care already inaccessible to far too many Americans.
There is little question who benefits from this bureaucratic maze: doctors and patients alike are frustrated if not maddened by the system, and insurance companies themselves are the lone stakeholders gaining from the system. In an election season filled already with so many surprises, one certainty is that health care will remain prominent on the agenda -- whether expanding but building more incrementally on the Affordable Care Act, moving to single-payer, or rolling back the ACA -- and one hope is that with this continued discussion, there should be greater emphasis on allowing questions of "medical necessity" and the timeliness with which those medical procedures be carried out be determined by those holding the medical credentials.
It turns out, despite the fact that peoples' propensity to get sick is not exclusive to insurance company business hours, insurance preauthorization often is required for the transfer to another hospital facility, or for certain procedures to take place. This can result in unnecessary delays in obtaining needed care, or being transferred to less reputable facilities that do not carry certain restrictions.
The Department of Health and Human Services defines insurance preauthorization as follows: "A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost." Such requirements can in some cases lead to extensive persuasion by doctors to insurance companies (that is, those who are not medical professionals but on the business end of the deal) that certain procedures, tests, transfers, are medically necessary. Issues of preauthorizations absorbed in 2006 an average of 1.1 hours per week from primary care providers, 13.1 hours per week of primary care nursing staffs, and 5.6 hours per week of primary care clerical staff. While insurance companies are barred from imposing prior authorization rules in the context of emergency care, some issues regarding interfacility transfers still apply, and should it become clear that a battery of tests must be ordered in the near future, a patient nervous about an impending diagnosis and treatment may have a barrage of insurance inquiries awaiting them first.
The fact is, this is just one of many ways in which we have nominally worked to expand health care insurance coverage while simultaneously making it profoundly difficult for people to actually utilize those benefits. Whether it is a large deductible that one must meet before benefits kick in, a large out-of-pocket maximum such that expenses can continue to aggregate, or a large coinsurance that can lead one to such conditions as asking their doctor to run fewer or less expensive tests, we often find ourselves crafting policies that perhaps work well enough for those wealthy enough to afford the out-of-pocket costs or poor enough to obtain government-sponsored insurance and credits, but with the middle class continuing to get squeezed. The matter of insurance preauthorization is in fact an equalizing force in that it is not about dollar amounts but rather red tape, navigating a complex system that is all the more challenging when medically compromised and potentially from a vulnerable population. And while parity laws are meant to ensure that medical and behavioral health are treated equally with respect to benefits, such laws are notoriously poorly enforced, with "medical necessity" looked upon with greater scrutiny in the behavioral health context, adding an additional barrier to a category of care already inaccessible to far too many Americans.
There is little question who benefits from this bureaucratic maze: doctors and patients alike are frustrated if not maddened by the system, and insurance companies themselves are the lone stakeholders gaining from the system. In an election season filled already with so many surprises, one certainty is that health care will remain prominent on the agenda -- whether expanding but building more incrementally on the Affordable Care Act, moving to single-payer, or rolling back the ACA -- and one hope is that with this continued discussion, there should be greater emphasis on allowing questions of "medical necessity" and the timeliness with which those medical procedures be carried out be determined by those holding the medical credentials.
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