Shalina Chatlani | (TNS) Stateline.org
Amina Tollin struggled with unexplained, painful symptoms for many years. Recently, she was diagnosed with polyneuropathy, a chronic nerve condition, and began using a wheelchair.
Her doctor recommended a blood infusion therapy that allowed her to live normally, but Medicaid stopped covering the therapy after a few months, using a process called prior authorization.
The monthly infusions cost around $18,000 each, and when Medicaid stopped paying, she could no longer afford them.
“The doctor proved I need it, but they just decided I don’t,” Tollin said. “It’s been terrible. I’m in pain.”
To control healthcare expenses and prevent unnecessary services, insurers have long required doctors to get approval before paying for certain drugs, treatments, and procedures. Recently, insurers have been using prior authorization more, causing delays and denials of care that are hurting or even killing people, according to many doctors and patients.
In the past few years, more than 25 states have considered laws to reduce prior authorization delays and denials. Nine states have passed new laws, as reported by the American Medical Association, which has supported them.
For example, a New Jersey law establishes a 72-hour deadline for most claims. Texas implemented a “gold card” system exempting doctors with a 90% approval rate from prior authorization. Washington state sets deadlines and requires insurers to automate the process for faster approvals, while Michigan requires prior authorization to be based on peer-reviewed criteria.
“It's about gaining momentum and seeing this in more and more states,” said Dr. Jack Resneck, former president of the American Medical Association. Many of the bills are based on the organization’s model legislation.
“We hope insurance plans will realize they have gone too far and are harming patients, preventing people from getting evidence-based, appropriate care,” Resneck told Stateline.
Insurers argue that prior authorization ensures doctors only prescribe medically necessary therapies and treatments, protecting patients and reducing healthcare costs overall. Robert Traynham, a spokesperson for AHIP, a trade group formerly known as America’s Health Insurance Plans, wrote in an email that 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.
Those supporting restrictions on prior authorization warn that the new state laws might not have strong enforcement mechanisms, so they may not have a significant impact.
Ron Howrigon, a former leader at insurance company Cigna and current head of Fulcrum Strategies, a company that specializes in insurance contracts, said the laws are “better than nothing” and that “there are definitely some people [they’re] going to help.”
But, Howrigon said, insurance companies are skilled at finding ways to avoid laws meant to hold them accountable, especially if the only type of enforcement against them involves third-party reviews or relatively small fines.
“Nobody should pretend that patients won’t have to deal with incorrect denials,” Howrigon told Stateline. “Because that’s not right.”
Furthermore, state laws generally apply to state-regulated private health insurance plans, which excludes the 65% of people who work for large firms and are covered by self-funded employer plans. And many of the state laws don’t apply to people on Medicaid, the joint state-federal health care program for people with low incomes, according to the National Association of Insurance Commissioners.
Earlier this year, the federal Centers for Medicare & Medicaid Services finalized a rule designed to expedite prior authorization in government insurance programs, including Medicaid and Medicare, the federal health care insurance program for people aged 65 and over and the disabled. The new rule, most of which will go into effect in 2026, requires a decision on “urgent” requests within 72 hours. But it applies only to “medical items and services,” not drugs.
‘Fed up’
Dr. Amy Faith Ho, an emergency medicine doctor in Dallas, said many patients whose treatments are delayed or denied through prior authorization often end up in her waiting room.
“At some point they just get fed up. But what’s sad to me is they did everything right,” Ho said. She added that some patients with chronic illnesses don’t end up in the emergency room, but they do experience a loss in quality of life. “We see those patients sometimes present as suicide attempts,” she said.
For patients with certain diseases and conditions, such as cancer, prior authorization delays and denials are a common occurrence: A 2023 study found that 1 out of every 5 cancer patients did not receive the care recommended by their treatment team because of the prior authorization process. In a 2022 survey conducted by the American Medical Association, 94% of doctors said prior authorization had led to a delay in care, and a third reported that prior authorization had led to a “serious adverse event” for a patient in their care.
States have generally tried to address the issue in four ways, said Kaye Pestaina, the director of the program on patient and consumer protection at KFF, a nonprofit research organization.
The first strategy is to shorten the amount of time an insurer is allowed to decide on a medication or service request.
The second is to reduce the administrative burden physicians experience, often by giving a pass to doctors who have a high rate of approvals — Texas’ gold card system is one example.
The third approach is to strengthen transparency and data requirements.
The fourth one focuses on the review process itself by requiring that decisions be made based on clinical data that has been reviewed by peers.
Pestaina mentioned that it could take a long time to figure out which strategy, or combination of strategies, would produce the best results.
In Texas, for example, the 2022 gold card law has had varied results so far. Doctors who have received the card say there's a more efficient process, but there aren't many of them: Only 3% of physicians had achieved gold card status by the end of last year, according to the Texas Medical Association.
Resneck, the former American Medical Association president, said, “We should see 97% of doctors getting gold cards instead of 97% not getting them.” He added, “That should really be upside down and in the other direction.”
Enforcement challenges
State insurance commissioners will mostly be responsible for making sure the state laws are followed. Many of the new laws give commissioners the power to investigate insurers, impose fines for not following the rules, and even take insurers to court to revoke their license to operate in the state.
But to find violations, commissioners will mainly depend on complaints from patients and doctors, according to the National Association of Insurance Commissioners. And Howrigon notes that doctors and patients won’t know to complain unless they are aware of their rights under the new laws.
Howrigon also stressed that fines and penalties issued by the state may not be enough to intimidate insurance giants who make tens of billions of dollars in profits. He also pointed out that in 11 states, insurance commissioners are elected and often receive campaign donations from the companies they regulate.
He suggested a better approach to enforcement would be to hold the medical directors within insurance companies responsible for decisions that harm patients.
Howrigon said, “If those doctors had the same accountability and responsibility as the doctors who are writing the prescriptions, meaning they could be sued for malpractice … all of this would go away.”
Under a prior authorization bill advancing in Oklahoma, insurance company medical directors could be held liable for medical malpractice, making them open to lawsuits.
Republican state Rep. Ross Ford, one of the cosponsors, said, “I have had doctors tell me this is some of the best legislation they’ve seen in the country. It’s fair to the insurance company and the patient. It provides the right balance of oversight, but also goes far enough to hold the insurance company responsible if they choose to deny a procedure.”
Three months of limbo
In Arizona, a bill has been introduced that would mandate insurers to honor prior authorizations for at least 90 days, even if the patient switches insurers. But according to the Arizona Department of Insurance, it would not apply to Medicaid.
This means it wouldn’t apply to Amina Tollin.
Medicaid finally approved Tollin for her infusions in late March. But through the three months of limbo, she says her symptoms — including pain, exhaustion, numbness and tingling — were agonizing.
She worries that at some point in the future, Arizona Medicaid might once again refuse to cover the infusions, which are covered for the next twelve months.
She said, "I feel like I succeeded, but it doesn't really count because there will be a completely new struggle in a year."
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