Doing your research is a good consumer practice for most purchases, but it is especially important when choosing health insurance.
If you buy a car lemon or a broken TV, you will be covered by consumer protection such as warranty and safety standards. But when it comes to being as important as your health insurance, you may be amazed at the fine print. Unfortunately, too few patients understand that insurance practices can leave them at the forefront of important medical claims.
Consumers may delay, confuse, or reject doctor-recommended treatments as millions of Americans are considering options during Medicare’s open registration season, which lasts until December 7. It is important to pay close attention to certain insurance restrictions.
One such limitation is called pre-approval (sometimes called pre-approval or pre-authentication). With prior approval, the insurance company representative must review and approve the treatment or service prescribed by the doctor before the insurance is applied.
Originally developed to control the cost of expensive or experimental procedures, prior approval often leads to frustrating delays in care and refusal of necessary medical care.
A good example: Aetna, one of the country’s largest and most profitable insurance companies, will impose new pre-approval requirements for all cataract surgeries across all plans this summer, regardless of patient health. did. In the first month of policy enforcement, tens of thousands of patients canceled vision recovery surgery. Some patients are awaiting approval, even though cataracts interfere with their daily lives and make driving and safe work difficult. , Increases the risk of falls and accidents.
Unfortunately, despite the ongoing pandemic, the number of medical services that require prior approval is increasing. Abuse of this cost-cutting practice is exacerbated across disciplines such as oncology, rheumatology, and psychiatry (only a few cases).
In fact, more than four of the five medical groups have reported increased pre-approval requirements since 2020, with 94% of physicians stating that pre-approval delayed the medically required care of patients. Sadly, according to a 2020 American Medical Association survey, 30% of physicians report serious adverse events in patients whose treatment was discontinued due to the insurance company’s pre-approval policy. Obviously, this is a growth trend that must be addressed.
Fortunately, Congress is currently working on amendments to protect patients from over-approval. The 2021 Act on Improving Timely Access to Care for the Elderly is a bipartisan law that streamlines the pre-approval approval process, avoids occasional abusive practices, and modernizes Medicare Advantage. The bill is gaining momentum in Washington. With more than 245 bipartisan co-sponsors, the bill is by far the majority in the House of Representatives and has been rapidly gaining support in the Senate since its introduction in late October.
In the meantime, consumers need to carefully consider their options.
Some plans may seem attractive at first glance, but digging deeper can reveal nasty policies such as pre-approval. Therefore, consumers are encouraged to do due diligence. Recognizing that buying health insurance can be complex and overwhelming, here are some good starting points:
- Carefully read the pamphlets and materials provided by each insurance company to see what restrictions are placed on the procedures you care about.
- Google “[Insurance company name]And “pre-approval” to see what policies are in place.
- Visit the Board of Specialists website to see what they are saying about each insurance company. You may be surprised at how well (or not so) a particular insurer adheres to clinical guidelines.
- If you have any questions, please ask. Insurers need to be transparent about the types of care that require prior approval and how often it delays or interrupts the treatment recommended by the doctor.
- Understand how you can work with your provider for steps that may require prior approval.
Due diligence during this open registration period may help you avoid being tied to plans that do not meet your unique needs.
Terry Wilcox is Executive Director of Patients Rising.
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