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States want to make it harder for health insurers to deny care, but firms might evade enforcement

Shalina Chatlani, on

Published in News & Features

For decades, Amina Tollin struggled with mysterious, debilitating pain that radiated throughout her body. A few years ago, when a doctor finally diagnosed her with polyneuropathy, a chronic nerve condition, she had begun to use a wheelchair.

The doctor prescribed a blood infusion therapy that allowed Tollin, 40, to live her life normally. That is, until about three months ago, when it came time for reapproval and Medicaid stopped paying for the therapy. It was the result of an increasingly common process among private and public insurers known as prior authorization.

The monthly infusions for Tollin's condition cost about $18,000 for each session. When Medicaid stopped covering the infusions, she simply stopped getting them.

"The doctor has shown why I need it and they just decided I don't," Tollin, who lives in Tucson, Arizona, told Stateline. "It's been awful. I'm in pain."

To curb health care costs and block unnecessary services, insurers have long required doctors to obtain their approval before they'll pay for certain drugs, treatments and procedures. But in recent years insurers have ratcheted up their use of prior authorization, causing delays and denials of care that are harming or even killing people, many doctors and patients say.

In the past couple of years, more than two dozen states have considered legislation designed to minimize prior authorization delays and denials, and nine states have enacted new laws, according to the American Medical Association, which has advocated for them.


A New Jersey law, for example, sets a 72-hour deadline for most claims. Texas created a "gold card" system that exempts physicians with a 90% approval rate from prior authorization requirements. Washington state sets deadlines and requires insurers to automate the process to speed approvals, while Michigan mandates that prior authorization requirements be based on peer-reviewed criteria.

"It really is just a matter of building momentum and continuing to see this in more and more states," said Dr. Jack Resneck, who stepped down as president of the American Medical Association last June. Many of the bills are based on the organization's model legislation.

"We hope insurance plans will recognize that they have taken this entirely too far and will recognize that they are harming patients and preventing people from getting evidence-based appropriate care," Resneck told Stateline.

Insurers argue that prior authorization ensures that doctors only prescribe therapies and treatments that are medically necessary, protecting patients and lowering health care costs for everybody. Prior authorization "is designed to ensure that clinical care aligns with evidence-based recommendations — not to deny or discourage patients from getting the care they need," Robert Traynham, a spokesperson for AHIP, a trade group formerly known as America's Health Insurance Plans, wrote in an email.


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