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Appealing Prior Authorization Denials: Can it be Effective for Emerging Technologies?
While radiologists and other providers may be discouraged by insurer denials saying the use of a technological advance is “unproven and investigational,” 82 percent of appeals for prior authorization denials were approved in 2021.
As medical innovations continue to transform patient care, physicians have found themselves stuck in an increasingly frustrating tug-of-war with insurers over access to cutting-edge innovations with patients being caught in the middle. Originally put in place to help contain health-care spending and curb unnecessary services, prior authorization policies are creating unnecessary barriers and delays to needed care, negatively impacting patient outcomes, and driving up costs in the long run.
According to a 2022 survey conducted by the American Medical Association (AMA), 94 percent of physicians said the prior authorization process delays access to necessary care for patients.1 Just as concerning, 86 percent of physicians reported that prior authorization requirements result in increased use of healthcare resources, leading to waste and red tape delays instead of the cost savings that insurers claim the process helps create.1
While prior authorization hasn’t changed much, the medical innovations available to patients have grown considerably. As a urologic oncologist, I use high-intensity focused ultrasound (HIFU), also known as focused ultrasound therapy, to treat patients battling prostate cancer. This procedure uses ultrasound energy to noninvasively destroy cancerous tissue in the prostate with less risk than surgery or radiation, and fewer life-altering side effects like erectile dysfunction or urinary incontinence.
Unfortunately, burdensome prior authorization requirements currently limit the uptake and adoption of this procedure and many other kinds of emerging, innovative technologies. Like many doctors, I work closely with my patients to identify a course of treatment that is most appropriate for them. Unsurprisingly, my patients increasingly prefer a less invasive HIFU procedure to avoid the side effects and risks of radical surgery.
By the time prior authorization requests for these services are submitted, both my patient and I have come to the decision that HIFU is the safest, most beneficial option for them. Ideally, that should be the end of discussion. Insurers should not interfere in the decisions made between doctors and patients.
This is not the case. Just recently, BlueCross BlueShield denied a prior authorization for one of my patients whom I was planning to treat with HIFU therapy. In the denial, the insurer claimed that the procedure is “unproven and investigational,” a claim that flies in the face of years of medical and scientific literature citing the success of focused ultrasound.
By restricting my patients’ access to technologies like HIFU, insurers are taking the practice of medicine out of my hands. Without having these HIFU therapy options in our treatment arsenal, providers are left with fewer options — waiting anxiously as the cancer grows or turning to aggressive radiation or surgery that introduces unnecessary complexity to the treatment process.
As physicians, we must keep the pressure on insurers to reexamine their policies when it comes to HIFU and other emerging technologies. One successful strategy, as time-consuming as it is, is to follow through with the prior authorization appeal process.
Currently, there is little pushback against prior authorization requirements, allowing insurers to continue to aggressively abuse the system. For example, only two-tenths of 1 percent of patients enrolled in the ACA marketplace filed an appeal in 2021.2 In the same year, there were two million prior authorization denials in Medicare Advantage.3 While only 11 percent of those were appealed by physicians, over 82 percent of those appeals were ultimately approved. In the short term, this may create additional administrative work, but the shockingly high success rate of prior authorization appeals makes it more than worth the effort for patients.
As medical innovation continues to increase the tools physicians have at our disposal, it is critical for providers to push payers to expand access to the latest, most effective FDA-approved technologies. In the meantime, we must continue to navigate the cumbersome prior authorization process, including appealing denials. Taking this final step to convince insurers to cover new procedures like HIFU therapy is likely easier than it seems and could be a meaningful way to expand access to care for our patients.
Dr. Frye is a urologic oncologist who currently serves as the Associate Professor of Urology and Vice Chair of Clinical Affairs for the Department of Urology at the University of Rochester Medical Center in Rochester, New York.
References
1. American Medical Association. 2022 AMA prior authorization (PA) physician survey. Available at: https://www.ama-assn.org/system/files/prior-authorization-survey.pdf . Accessed May 13, 2024.
2. Pollitz K, Lo J, Wallace R, Mengistu S. Claims denials and appeals in ACA marketplace plans in 2021. KFF. Available at: https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/ . Published February 9, 2023. Accessed May 13, 2024.
3. Biniek JF, Sroczynski N. Over 35 million prior authorization requests were submitted to Medicare Advantage plans in 2021. KFF. Available at: https://www.kff.org/medicare/issue-brief/over-35-million-prior-authorization-requests-were-submitted-to-medicare-advantage-plans-in-2021/ . Published February 2, 2023. Accessed May 13, 2024.
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