Delaying and denying authorizations for medically necessary care. Forcing patients to try potentially ineffective treatments through step therapy, or “fail first” protocols that require patients to try and fail certain treatments before the insurer will authorize more costly treatments. Placing limits on where patients can access care.

These are only some of the troubling policies being enacted by some commercial health insurers that are compromising patient safety and driving up costs to the entire health care system, according to a new report we released this week.

These policies have negative effects on patients and care providers. Responding to an American Medical Association survey last year of more than 1,000 physicians, nearly 90% reported spending two days a week completing prior authorizations, an inefficient use of staff time that contributes to workforce burnout at a time we can least afford it.

The report also details how some insurers frequently establish flawed or overly stringent medical necessity policies that prevent patients from obtaining the necessary care recommended by their physician, and how some leverage their market power and position to steer providers to purchase their auxiliary products that drive up administrative costs and line insurer pockets.

At the same time, the cost of commercial insurance is increasing at an unsustainable rate — squeezing individuals and families, employers and public programs. The average family insurance premium has increased 47% over the past 11 years — faster than general inflation and more than any other part of the health care system. This contrasts with hospital prices, which have grown an average of 2.1% per year over the last decade.

Commercial health insurers are the dominant source of health coverage for most Americans and employers, and Medicare and Medicaid often rely on these insurers to administer their health benefits. The AHA supports a vibrant private insurance market to support consumer choice in their benefits. However, these insurers must meet their obligations to their enrollees.

The AHA continues to push back on harmful policies that put patient care at risk, burden our workforce and add billions in unnecessary administrative costs to the health care system. And we won’t stop.

We’re working on many fronts to make sure lawmakers, policymakers and the public understand these problematic policies, as well as offer solutions. For example:

  • We’re calling for greater congressional oversight to protect access to care for Medicare Advantage beneficiaries. We support legislation now advancing through Congress to streamline MA plans’ prior authorization requirements. On Wednesday, the House Ways and Means Committee voted to advance to the full House the Improving Seniors’ Timely Access to Care Act (H.R. 8487), AHA-supported legislation that would streamline prior authorization requirements under Medicare Advantage plans.
  • We’re urging the Department of Justice to establish a taskforce to conduct False Claims Act investigations into commercial health insurance companies that are found to routinely deny patients access to services and deny payments to health care providers.
  • And we’re asking the Centers for Medicare & Medicaid Services to take action to hold plans accountable for egregious practices through increased oversight.

At the same time, we’ve launched Insurer Watch, a new solution from the AHA in collaboration with Hyve Health that can help hospitals uncover how often their organization’s payment claims are denied, determine if those denial rates vary by payer or service line, and compare their organization’s metrics to other providers and peer groups. This will provide access to actual data from the field and be an important tool in our advocacy efforts to address commercial health plan abuses.

As a number of experts in our field have pointed out, insurance companies are not licensed to practice medicine. We’ll continue to pursue these efforts and any others necessary to protect patients’ health and ensure that medical professionals, not the insurance industry, are making the key decisions in patient care.

Related News Articles

The AHA May 2 released a new report highlighting how hospitals and health systems continue to experience significant financial pressures that challenge their…
People enrolled in Medicare Advantage are more likely than those in traditional Medicare to report delays in care due to needed insurance approvals, according…
Andrea Preisler, AHA’s senior associate director of administrative simplification policy, explains why the recent final rule requiring Medicare Advantage,…
The Centers for Medicare & Medicaid Services (CMS) Jan. 17 finalized new regulations aimed at reforming the prior authorization process.The new rule will:…
The Centers for Medicare & Medicaid Services yesterday released FAQs clarifying coverage criteria and utilization management requirements for Medicare…
The Centers for Medicare & Medicaid Services will accept comments through March 1 at 6 p.m. ET on its advance notice of proposed changes to Medicare…