KMA: Ten second or less — health insurers use prior authorizations to delay, deny care; reform is needed

Kentucky Medical Association

Count to ten.

That's how long at least one health insurer believes it takes to review whether you need a test, medication or other health care service.

Modern-day life is hectic and being sick or suffering from a chronic condition like asthma or diabetes only adds to the burdens we all face. Those burdens are only compounded when your treatment is hampered by the dreaded need for "prior authorization" or other review from your insurer before they agree to pay for it. Even if the treatment is eventually approved, the prior authorization process itself creates hardships for people at a time when they least need them.

Unfortunately, as medicine has modernized, health insurers use technology to deny care at astounding rates. One needs to look no further than a recent ProPublica article that highlights how Cigna does it. The company uses a computer program that "flags" mismatches between what a patient's physician diagnoses versus what the company considers acceptable tests and procedures for those ailments. Once "flagged," claims are supposed to be reviewed. According to the article, this so-called review was, to say the least, very brief.

One reviewer highlighted in the article rejected 121,000 claims in the first two months of 2022. Rejected – not reviewed. Assuming this reviewer worked a normal eight-hour workday, five days a week, during those two months, the reviewer worked 328 hours during that time. 121,000 claims rejected over the span of 328 hours is the equivalent of rejecting 368 claims per hour, which amounts to 6.13 claims rejected every minute, making the rejection rate one every ten seconds. That's without accounting for breaks, holidays or any claims the reviewer did not reject. One former Cigna executive described this process as "a system built to deny claims." No kidding.

Insurance companies' prior authorization practices require patients and physicians to spend countless hours submitting and resubmitting paperwork, medical charts, and waiting on hold just to get a much-needed medication, test or procedure approved by the insurance company. A survey of Kentucky physicians last year conducted by KMA found a litany of horror stories about how this process denied or delayed care, including patients who died while waiting. This is unacceptable.

One way to reform this system is to bypass it altogether.

Legislation taken up during the 2023 Kentucky General Assembly would have prevented insurers from imposing prior authorization on physicians who rarely get their requests for prior authorization denied.

This makes sense, not only for the patient and the physician, but the health insurers as well.

Why go through the trouble of setting up and operating such systems in situations where they are not needed?

KMA will continue to engage lawmakers over the coming year regarding the need for this common-sense approach so that the General Assembly can enact much needed reforms during the 2024 legislative session.

Reform is needed to rein in insurers whose first instinct is to deny care. How much is it needed?

Count to ten.