This commentary is by Kelly Lange, vice president of managed care contracting for the University of Vermont Health Network
In early March, a patient went to neurosurgery at the University of Vermont Medical Center for testing on her brain for a serious condition. The specialist recommended more advanced imaging and scheduled an appointment.
Because it wasn’t an active emergency, the imaging required prior authorization from the insurance company. Two and a half weeks later, when the patient arrived for her imaging appointment — after multiple phone calls and escalation by the UVM Medical Center team — it still had not been authorized.
At that point, the hospital either has to perform the procedure and not get paid — contributing to well-documented financial challenges that make it difficult to provide care to all future patients in need — or tell the patient she may receive a bill for tens of thousands of dollars, for a scan her provider told her she needs. In this case, thankfully, the authorization finally came in — an hour after the appointment.
This happens all too often, causing stress and confusion for patients, and can lead to delayed care.
Our team at UVM Health Network shares this frustration with our patients, along with our independent practitioner colleagues and hospitals across the state and country. We believe health care decisions are best made between patients and their providers, and bureaucracy should not block timely access to care.
Prior authorization
At its most basic, prior authorization — when health care providers must get approval from a patient’s insurance company before certain services, procedures, medications or treatments are covered — does have a purpose. Along with similar policies, it’s meant to avoid unnecessary treatment or medication that could cause adverse effects or complications and to reduce health care costs.
But too many people reading this have had to fight for a treatment that both provider and patient agreed was necessary.
Others have had to seek reauthorization for a medication they’ve been taking for years or had to try a medication they know doesn’t work before being approved for the one they need. Or they got a needed treatment only to find the claim was denied.
Other times the challenge is with medical equipment a patient needs to leave the hospital or limits to where patients can go to receive services.
According to a 2022 survey by the American Medical Association, more than 90% of doctors say their patients have delayed their care because of prior authorization. A third of doctors said such delays led to serious problems for their patients, like a life-threatening event or hospitalization.
Changing rules
Our patients and providers deserve consistent, predictable and rational rules to follow when seeking and providing life-saving care, and that’s not what is happening.
These policies vary between insurance companies, with different rules for different plans, even for similar treatments. For example, one insurance company might require a prior authorization for a scan, but another might not. A third company might follow completely different rules.
The rules change frequently — our team at UVM Health Network sees about 2,100 changes to these types of policies every year. That’s 40 per week. If it’s difficult for our team of experts to stay on top of all these changes, how are patients supposed to know what to do? It’s like if the fire department needed approval from the water utility before tapping a hydrant to put out a fire — but only on certain streets.
When one of the rules isn’t followed exactly, claims get denied. It takes about an hour per claim for our staff to review the denial, fax medical records and conduct a follow-up, hoping the care that was provided will be covered.
It costs $12 million to $16 million every year just at UVM Health Network because insurance companies are taking too long or deciding that care provided by our expert clinicians wasn’t “medically necessary.”
This means barriers to access to care for patients, increased costs for everyone and frustration among providers. We have doctors and nurses spending hours fighting for treatments and medications our patients need.
What Vermont can do
Vermont’s lawmakers have joined several states in taking up the issue. With a remarkable unanimous 137-0 vote, the Vermont House passed a bill that removes many of the bureaucratic barriers limiting patient care.
The bill, H.766, reduces the time insurers have to respond to prior authorization requests, limits when reauthorization is necessary, requires health plans to grant some exceptions to prescription drug step-therapy requirements, and directs Vermont’s Department of Financial Regulation to prohibit prior authorization requirements for certain medications and services. It would also require the practical change of having insurers, not providers, collect cost-sharing amounts from patients.
Providers statewide — and all of us at UVM Health Network — thank the House Health Care Committee and all of our representatives for their careful consideration of this legislation — and especially for their focus on patient access to care.
Vermont has a chance to improve our health care system for all by making insurance policies more predictable, consistent and effective. We hope the Senate will keep patient care front and center in their deliberations.
