Electronic Prior Authorization by 2026

[somarco]

Prior authorization is a cost containment tool used by insurers in which providers seek approval for certain drugs and services. Physicians have long complained that the amount of prior authorization requests has ballooned in recent years, causing undue administrative hardships for practices.


https://www.fiercehealthcare.com/pa...t-electronic-prior-authorization-systems-2026

"Cost containment" . . . saving money for the carrier at the expense of the patient

PA impacts patient comfort and care as well, in some cases delayed treatment could impact outcome.

Apparently only a handful of clients rarely, or never, experience these delays, or if they do have delays, they never complain . . .

 

[sshafran]

"Cost containment" . . . saving money for the carrier at the expense of the patient

Do you think a doctor has ever over prescribed, or over tested, or recommended treatments which were unnecessary?

I do.

Therefore I'm not opposed to PA. But I have a general distrust of doctors.

Kinda like my dentist (ahem, former dentist) who too individual tooth X-rays of several of my kids teeth. Not covered by insurance. At the front desk they wanted me to pay an arm and a leg.

No, you did not get my prior authorization for individual tooth X-rays. Not paying.

Yet had it been Medicare and a medical claim - no problem. Doc just made some $$$

 

[DonP]

Do you think a doctor has ever over prescribed, or over tested, or recommended treatments which were unnecessary?

I do.

Therefore I'm not opposed to PA. But I have a general distrust of doctors.

Kinda like my dentist (ahem, former dentist) who too individual tooth X-rays of several of my kids teeth. Not covered by insurance. At the front desk they wanted me to pay an arm and a leg.

No, you did not get my prior authorization for individual tooth X-rays. Not paying.

Yet had it been Medicare and a medical claim - no problem. Doc just made some $$$

Somarco is advocating drs and hospitals bill as they please . No checks and balances . The only difference is CO’s are making the money instead of the dr’s . All ages 65 and under must go threw prior authorization. All of a sudden for a senior it’s no longer ok ? Drs are pissed because there held accountable.

 

[somarco]

@sshafran we have been to this dance before, but I just want to clarify, you believe that an insurance carrier is in a better position to prescribe treatment for a patient they have never examined, than someone with a medical degree . . . correct?

 

[sshafran]

@sshafran we have been to this dance before, but I just want to clarify, you believe that an insurance carrier is in a better position to prescribe treatment for a patient they have never examined, than someone with a medical degree . . . correct?

I believe they are in a good position to prevent over-prescribing. A healthy dose of "hold on a minute" is good.

Case in point: I'm not a dentist. My kids did not need individual tooth X-Rays.

Do you think I had bad judgement there in denying the authorization, just because I'm not a dental school graduate?

I've said no to many things over the years. I learned the hard way as I'm self pay on everything. "How necessary is this?" is a question 95% of people are afraid to ask a doctor. Oh, I have a 3% risk of ___? I'll take my chances, doc.

To directly answer:
you believe that an insurance carrier is in a better position to prescribe treatment for a patient they have never examined

No, but I do think they are in a position to (a) question and challenge and (b) listen to the provider's justification.

They (the insurance carrier) can't just say no for fun. There are protocols.

Medicare should not be a provider's blank check. We both know it is with little to no oversight.

 

[somarco]

Medicare should not be a provider's blank check. We both know it is with little to no oversight.

Medicare is not a blank check for the provider.

Medicare adjudicates claims before paying . . . matching ICD codes against CPT. Claims are routinely denied if the dx coding does not support the treatment.

When Part B claims are denied the beneficiary is not liable to pay the claim absent a signed ABN form. Both my wife and I have experienced this first hand and I have seen it happen with clients as well.

Medicare does require pre-authorization for certain DME, but not treatment or diagnostic testing.

MAPD carriers are not allowed to underwrite enrollment applications so the only risk protection they have is to deny and delay claims.

Neither system is carte blanche. Neither is perfect.

I have personally witnessed more harm done under managed care plans than with a retrospective payment system with OM. Also, I worked in the individual major med and group insurance market for a number of year before managed care was a "thing". Were there abuses? Yes, but managed care has not eliminated manipulation of the system and probably has done little to curtail it.

OM has oversight, but not micro-management.

 

[DonP]

So let’s get to one of the main root complaints against mapd . It’s skilled nursing . We always here they kicked them out early . So obviously with orginal Medicare they basically can stay unlimited as long as the dr and facility says medically necessary. In mapd the dr has to prove its medically necessary. Sure there’s times mapd pushes people out early . But there’s 10 times more times people stay longer than necessary due to no checks and balances .


I recently had a woman call me from the hospital complaining Humana denied their request to go from the hospital to a snf . I told her the dr must contest it . Never heard another word . During my nearly review she said she loved Humana and wanted to stay put . If someone’s middle to upper income income and in bad health I encourage med sup very heavily .This arguments been going on for yrs . But the migration speed to mapd is stunning . Can’t wait to see the 2023#’s in late Jan . I expect over 50% to be on mapd . 7 yrs ago it was 25% or so .

 

[Travis Price]

It's one of multiple complaints.

 

[Travis Price]

.This arguments been going on for yrs . But the migration speed to mapd is stunning

No offense, it's not really that stunning.

Medicare saves money by having the insurance company administer plans.
The company makes money by getting a guaranteed premium payment every month from Medicare to use managed care criteria.
The agent makes out by selling MAPD with crazy new to Medicare fees and HRA, and HI/Cancer comms.

Look, MAPD is exponentially better than ACA. However, being shocked or amazed or whatever because of adoption is odd. The amount of money thrown around at every level would make me shocked if it wasn't adopted as much.

Just FYI, CMS is getting tons of complaints... just because YOU don't get them doesn't mean they don't happen.

 

[somarco]

The amount of money thrown around at every level would make me shocked if it wasn't adopted as much.