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Designed by health insurance companies to prevent doctors from deploying expensive, ineffectual procedures, prior authorization — sometimes called preauthorization or pre-certification — has become a confusing maze that denies or delays care, burdens physicians with paperwork, and perpetuates racial disparities. Proposed federal rules may not be enough to solve the problems.
Eric Tennant’s doctors recommended histotripsy, which would target, and potentially destroy, a cancerous tumor in his liver. But by the time his insurer approved the treatment, Tennant was no longer considered a good candidate. He died in September.
After Eric Tennant died, his widow vowed to speak out against West Virginia’s Public Employees Insurance Agency, which had denied cancer treatment recommended by Tennant’s doctor. Her efforts paid off. In March, West Virginia’s governor signed a bill to protect some patients from harm tied to prior authorization.
Health insurers issue millions of prior authorization denials every year, leaving many patients stuck in a convoluted appeals process, with little hope of meaningful policy change ahead. For doctors, these denials are frustrating and time-consuming. For patients, they can be devastating.
The fatal shooting of UnitedHealthcare CEO Brian Thompson prompted both grief and public outrage about the ways insurers deny treatment. Republicans and Democrats agree prior authorization needs fixing, but patients are growing impatient.
A Maine woman sought care at a clinic for a tick bite, then paid full price after her insurer denied coverage. Its reason? She didn’t have preapproval for the walk-in visit, even though testing later detected the pathogen that causes Lyme disease.
A pilot program testing the use of artificial intelligence to expand prior authorization decisions in Medicare has providers, politicians, and researchers questioning Trump administration promises to curb an unpopular practice that has frustrated patients and their doctors.
Many people don’t know they can fight a health insurance denial, let alone how to do it. Here are practical tips for consumers who want to appeal a prior authorization decision.
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Patients and providers say health insurers’ preapproval requirements lead to delays and denials of needed medical treatments. Insurers argue that prior authorization keeps costs down.
A state lawmaker wants health insurers to disclose denial rates and explain those denials as anger grows over rising costs and uncovered medical care. If the bill is signed into law, health experts say, it could be one of the boldest attempts in the nation to rein in denials.
Dozens of health insurance companies pledged on Monday to improve prior authorization, a process often used to deny care. The announcement comes months after the killing of UnitedHealthcare executive Brian Thompson, whose death in December sparked widespread criticism about insurance denials.
Lauren Sausser
Darius Tahir
Erin McLaughlin, NBC News
Jason Kane, NBC News
Phil Galewitz
Christine Mai-Duc
Mike Dennison
Bram Sable-Smith
Sarah Jane Tribble
Brianna Soukup
Ryan M. Kelly
Christopher Smith
Logan Cyrus
Desiree Rios
Sabriya Rice
Emmarie Huetteman
Samantha Young
Matt Volz
Terry Byrne
Gabe Brison-Trezise
J.J. Evans
Oona Zenda