Prior authorization nightmares prompt Kansas lawmakers to consider new regulations

TOPEKA, Kan. (KCTV) - A debate is raging nationally regarding prior authorization. You’re probably familiar with it. It’s a common practice in medicine today. Your doctor says you need a particular medicine, or diagnostic test, but your insurance company has to approve it first. Getting it approved can take weeks—or even longer.

The process impacts large health systems and private practices.

“It has really deep-reaching impacts to healthcare, and most importantly to the patients,” said Dr. Timothy Williamson with the University of Kansas Health System. “There’s really has been negative impact to patients.”

Prior authorization is a requirement by most health plans. Its purpose is to contain costs and confirm the service or medication is “medically necessary.” But many doctors believe it has gotten out of hand. The first submission is routinely denied.

“It will usually get denied on the first pass,” said Dr. Daniel Sanchez, a family practice physician in Plainville, KS. He says the first look is usually done by someone who is not a physician. It’s then denied on a second pass, “And finally, there’s a lot of times I’ll send it to an independent reviewer, in that specialty, you know, for the final appeal.”

It’s frustrating—for patients and physicians.

“The intention is understandable,” said Dr. Sanchez. “I don’t want to use that as my first line therapy. I don’t want to use it for somebody who doesn’t really need it. And that’s about as far as it should go. It seems that the insurance companies use this process to deny and I could easily see a patient or a doctor just throwing up their hands and saying, ‘Well, I don’t have the time to deal with this.’”

The process takes hours away from doctors and their staffs.

The Kansas Hospital Association has introduced a bill to modernize the prior authorization process and hold insurance companies accountable.

“We’re not asking for prior authorization to go away,” said Dr. Williamson. “But we are asking for some guardrails that make it less burdensome.”

The American Medical Association recently surveyed physicians. Their survey showed:

• 34% of physicians reported that prior authorization has led to a serious adverse event for a patient in their care.
• 24% report that prior authorization has led to a patient’s hospitalization.
• 18% report that prior authorization has led to life-threating event or required intervention to prevent permanent damage

The process takes hours away from doctors and their staffs. That same survey showed on average, a practicing physician completes 41 prior authorizations each week. Physicians and their staff spend almost two business days each week completing PAs.

Both physicians we talked with say what’s needed to help ease the burden is transparency and faster responses.

“I think the biggest thing is how unresponsive they are, care gets really delayed,” said Dr. Williamson. “Can you imagine being a cancer patient, waiting potentially weeks to have the necessary stage and diagnosis diagnostic exams, so you can get started on your chemo? Because you’re waiting for the insurance approval.”

“It’s like they’re holding the criteria for using that medication close to their vests,” said Dr. Sanchez. “We have no way of verifying that whether or not the patient actually meets their criteria for that treatment.”

We would like to know about your experiences with prior authorization. Please contact us at investigate@kctv5.com.

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