In Morganton, NC North Carolina, is a recipe for the states that consider the legislation to regulate the prior approval and claims of the health insurers. (Chris Carlson | Die Associated Press)
Health insurance companies are increasingly being checked because they are supposed to be used Artificial intelligence bots And algorithms to quickly refuse the routine or the life -saving care of the patients – without actually checking their claims.
The top -class murder of Unitedhealthcare, CEO of Unitedhealthcare, Brian Thompson, has even more attention to the so -called prior approval, the process with which patients and doctors have to ask the health insurers to approved medical procedures or medicines before the procedure. There had been Protests and outrage For months before Thompson’s death and Unitedhealthcare was accused of the practices of the company for months before Thompson’s death A class action Ai to apply claims wrongly.
Since more and more patients and doctors express their frustrations, the states react with legislation to regulate the prior approval and the reviews of claims. So far this year the legislators in More than a dozen states Think about measures that, for example, Limit the apply of AI When checking claims; Exclude certain prescription drugs From previous authorization rules; Make sure that mental health care is not delayed in emergencies more than 48 hours; And demand that insurers evaluate committees Contained licensed doctors, dentists or pharmacists with clinical experience.
Insurers have long asked doctors to receive their approval before paying certain medication, treatments and procedures. They claim that it is necessary to contain the health costs and limit unnecessary services. But many doctors and patients say that practice has come out of control and caused delays and care for care that harm people and even kill people.
In A Survey last year Due to the American Medical Association, 93% of doctors stated that the prior authorization practices of the insurers delayed the “necessary care” for their patients. 29 percent stated that such delays had led to a “serious undesirable event” such as hospital stays, eternal injury or death.
In 2023, insurers sell the plans to the marketplaces created as part of the Affordable Care Act contested A combined average of 20% of all claims. Of the 73 million in-net work claims they have rejected, only 1% appeal were filed, according to the information KffA research group for health policy.
The federal role
Under the bid administration the Federal Trade Commission and the Ministry of Justice Take a firmer hand against healthcare companies that allegedly participate in behavior, which led to a restricted and more high-priced care of patients. The Administration also approved Regulate The demand that Medicare and Medicaid’s plans will create an optimized electronic process for checking claims from 2026, make decisions faster and provide specific reasons for the rejection of care.
According to Timothy McBride, an analyst for health policy and co-director of a program at the Institute for Public Health at Washington University in St. Louis, it is hard to hold insurers accountable.
“Every part of the healthcare industry – hospitals, pharmaceuticals, insurers – all have a lot of concentrated power,” said McBride in a telephone interview. “And if someone doesn’t accept it directly, it will stay that way. I think the Biden administration tried to record it, but has not made much progress.”
It is unclear whether the Trump administration and the congress will reverse the course. During his hearing for confirmation on March 14th, Dr. Mehmet OZ, President Donald Trump’s election, to lead the centers for Medicare & Medicaid Services, defend The apply of artificial intelligence when checking claims.
“AI can be used for good or evil, and it largely depends on who uses it and for what purpose,” Oz told the members of the US Senate Financing Committee. “I think AI could play an important role in acceleration of the pre -autorization.”
In the past, Trump has supported measures to support patients, e.g. B. increasing the hospital Price transparency and reduction prescription drug pricesMcBride noticed. “Republicans and conservatives are generally anti-regulation,” he said. “My gut feeling would be that they withdraw on the bidges.”
States have only restricted powers to act themselves. They only have authority through state-regulated health plans, which include Medicaid, plans for state workers and guidelines that buy residents from the ACA marketplaces. Approximately 90 million people are so covered. The state law does not apply to the 156 million employees, pensioners and relatives who receive their coverage by employers sponsored health plans that are regulated by a federal law that is known as known Erisa.
In addition, the health insurance companies are enormous and have deep pockets so that they can easily absorb state fines.
Kaye Pestaina, the director of the program to protect patients and consumers at KFF, said that the states play an crucial role.
“Much of the focus on the prior approval at the federal level has from state protection.
What states do
According to Pestaina, states try out a number of solutions. For example, states such as Arizona, Michigan and Pennsylvania have given their insurance supervisory authorities more power to access refusal information in order to remove decisions or possibly enforce state rules. And mostly these efforts have supported.
There is a role in a certain supervision to ensure that things are covered. But at the moment I think the system has come out of balance.
– North Carolina Republican State Rep. Timothy shipowner
In Pennsylvania, Republican Senator Kristin Phillips-Hill pushed through two-party legislation 2022 to rationalize earlier authorization practices for state -regulated health plans after hearing numerous symptoms of patients and doctors.
The legislation created one Independent external evaluation Organization that enables Pennsylvanians to submit an online form to request a review if your insurer refuses service or treatment. If the review organization decides that the service should be covered, the insurer must do so. Before that, the patients were only able to turn to one federal checking process that may be more hard to navigate and take more time.
“Our reforms have created clear rules, clear schedules for the previous approval process and removed ambiguities or uncertainties from the system through which the insurers could sometimes exploit, and providers were able to be confused,” Phillips-Hill told Steline. “Before this reform, if they had a rejection from their insurer, they had very little back.”
The program started in January 2024, and in its first year the Pennsylvania insurance department raised half of UM 517 rejectionsmade up for the claims of 259 people.
Jonathan Greer, President and CEO The Pennsylvania Insurance Association, said that his trading group had worked with the legislators to make an agreement on how the previous approval process should be changed in a way that has worked for insurers and patient lawyers. Greer says Pennsylvania could be a model for other countries.
“I think the prior approval was wrongly characterized as a reason to say no by insurers,” said Greer. “The purpose of the prior approval must ensure that you know that the care you receive matches with the care you need.”
In North Carolina, the Republican MP Timothy Reeder hopes that his Preparatory law I will bring it over the finish line this year. Shipowner The invoice Would determine tight deadlines for the insurers’ application decisions and obliged companies to licensed practitioners in their damage inspection committees. The insurers would also have to publish a list of services for which they need approval.
“I’m not saying that we have to get rid of it completely,” Reeder told Stateline. “There is a role for some supervision to ensure that things are covered. But at the moment I think the system has come out of balance.”
However, some state laws have proven to be less effective than advertised.
In 2021, Texas issued a unique law that created a law created.Gold cardStandard, according to the doctors, whose pension recommendations are approved by insurers in at least 90% of the cases, are exempt from the previous approval process. From the end of 2023, only 3% of Texas doctors earned gold card status with gold cards. According to the Texas Medical Association.
Therefore the group pushes legislation This would have to require the insurers to report which pre -authorization exceptions they granted and rejected and how many claims to an independent review were. Dr. Zeke Silva from the legislative Council of the Texas Medical Association said that it would be “in the same spirit” “in the same spirit” as what Pennsylvania did.
“Our focus with that [Texas Medical Association] Is our doctors able to offer the best possible care? And we want this to be free from stress, “said Silva to Stateline.” We want third parties to occur and the care inappropriately deny that our doctors and our patients believe that they are in their best interest. “
Stateline reporter Shalina Chatlani can be reached schatlani@stateline.org.
