Architect of Market Innovation | Catalyst for Culture & Value Creation | Senior Executive| Board Member
Really? Denials were issued on 7.4% of all MA Prior Authorization requests in 2022. Prior Authorization Denials were UP 24% between 2019 and 2022. Sorry folks, this is ridiculous. Plans are using denials as a financial management tool that has little to do with managing member health. On appeal, only 2 in 10 denials are upheld. Here is the game... plans know that only 10% of denials are appealed. They make the process difficult, time consuming for providers and keep the rules vague. When the MA program started to gain traction in the early 2000's, denials were less than 2%. Do we really think that providers are 400% worse at practicing medicine than they were in 2000? Plans should be required to publish the exact criteria they are using on each prior authorization and should make an appropriately boarded specialist available in real time for a pre-submission discussion and binding authorization and payment commitment. Do we still believe plans are not practicing medicine? If plans don't stop pushing the envelope, politicians will remove prior auth as a tool.
Agree that payers will look at high utilization rates or higher cost services that are driving medical expense as short term tools to manage cost . It creates barriers that we see as a provider of care and adds increase burden and cost on the insuree and provider. I have always advocated for systems and process that improves access, reduce barriers, and helps insurees navigate their care needs and treatment which requires more longitudinal management
Retired: Large Group Health Plan Professional ( 1972-2022)
2moGreat Points. Because Prior Authorization on ESI Health Plan Spend, began in the 1980s on Hospital Care ( Admissions) then Surgical and Drugs in 1990s) as a result of increasing Price in PPO & Rx Plans. Of course they have increased in Use & Denials because their purpose is Cost Containment: not Medical Appropriate or Drug Effectiveness. With 6-8% M and 11-13% D Trend in 2025, what you brilliantly show and state to us, will continue unabated as Employers ( and Brokers) continue to price-focus instead of Outcome- focus in their Group Health PPO and Prescription Drug self-insured annual Plan Expense; to mitigate the rising number and cost of their High Cost Claimants.