In Michigan, insurers must report annual prior authorization data, including the number of requests denied and appeals received. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days. Meanwhile, some states have passed their own laws governing the process. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “Seven days is still way too long,” said Dr. The proposed rule was scheduled to be open for public comment through March 13.Īlthough groups like AHIP, an industry trade group formerly called America’s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don’t go far enough. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. “It’s really devastating, these unnecessary delays.” Shikha Jain, a Chicago hematologist-oncologist. “The prior authorization system should be completely done away with in physicians’ offices,” said Dr. So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.įamily health care coverage at work tops $22,000 a year In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization. Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care. “It limited her options.”įew things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years. Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. Despite treatment, she died in the hospital within six weeks of being admitted. Doctors started a regimen of chemotherapy, but it was too late. A tumor in her chest had become so large that it was pressing against her windpipe. Months later, Chestnut, struggling to breathe, was rushed to the emergency room. “On at least four or five occasions, she called me up, hysterical,” Roux said. The biggest health insurance mysteries, and how to decode them In some cases, step therapy requirements may require members to first try over-the-counter products.Misunderstanding common health insurance terms can be costly for your wallet and health. Step therapy requires that the member has tried an alternative therapy first, or that the prescriber has clinically documented why the member cannot take the alternative therapy. For oncology and supportive care medical benefits drugs, submit requests to Carelon Medical Benefits Management (formerly known as AIM Specialty Health ®). Learn about submitting requests to Carelon electronically and through other methods on Blue Cross Medical Benefit Drugs or on BCN Medical Benefit Drugs.For most medical benefit drugs, including CAR-T cell therapy drugs, submit requests through NovoLogix ®. Learn about submitting requests through NovoLogix and through other methods on Blue Cross Medical Benefit Drugs or on BCN Medical Benefit Drugs.Learn about submitting requests electronically and through other methods on Blue Cross Pharmacy Benefit Drugs or on BCN Pharmacy Benefit Drugs. For pharmacy benefit drugs, submit requests through CoverMyMeds.Submitting prior authorization requestsįor drugs that require prior authorization, providers should submit requests as follows: We require providers to request prior authorization for certain medicines, such as specialty drugs, to ensure certain clinical criteria are met. To help make sure Blue Cross Blue Shield of Michigan and Blue Care Network members receive the most appropriate and cost-effective therapy, we require providers to take additional steps before certain drugs are eligible for reimbursement.
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