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Boston Globe

Insurance companies delay and deny needed health care. Here's how to stop that.

The insurance companies wanted to show they were 'doing something' to help control rapidly rising health care costs. Some insurance companies made money charging extra for 'pre-admission certification.' There was no evidence then that prior authorizations for any medical test or procedure would protect patients, improve care quality, or save money. Forty years later, there is still not much evidence they do any good. In fact, they cause harm. About 25 percent of physicians in Advertisement Problems with prior authorizations are responsible for almost half of Advertisement Requiring insurance companies to publish their prior authorization denial rates on all marketing materials and platforms would let patients and plan sponsors know how likely it is that their claim would be paid before they bought the insurance. The Affordable Care Act requires insurance companies to compile denial rates for plans offered on its marketplaces, but the information is not widely available, and the regulations to publish it have not been enforced. There are no similar requirements for commercial, Medicaid, or Medicare plans. Denying claims is a very effective way for health insurance companies to make money. Only about half of all bill denials are ultimately overturned, resulting in payments to care providers. The process for appealing a denial is so complicated that fewer than 1 percent of patients bother to appeal, and most of them lose in a process that is controlled by insurance companies. Very few patients even know they have a right to an external appeal when the insurance company turns them down. Pharmacy benefit managers, often owned by health insurance companies, increase their profits through prior authorization. Sometimes they pay for only the brand-name drugs the benefit managers get a kickback for promoting. Transparent, speedy, and independent reviews of medical care, prescription, and bill denials can be implemented if the companies and agencies buying insurance tell the insurance companies to do so. Advertisement Ending prior authorization, publishing denial rates, and forcing speedy, fair appeals would eliminate the majority of medical claim denials and delays in care. These changes would increase access to medical services and reduce patients' anxiety. They would also create an atmosphere for legitimate research into policies that improve patient outcomes, improve quality of care, and prevent wasteful, harmful medical practices. David L. Rosenbloom is a professor emeritus at Boston University School of Public Health. He served as commissioner of health and hospitals for the city of Boston from 1975 to 1983.