Prior-Authorization Rules Expanded by Biden Administration in Response to Patient Advocacy

Washington, D.C. – The Biden administration has issued a new set of rules aimed at curbing the use of prior authorization by private health insurance companies. Prior authorization is a complex process that requires individuals to seek permission from their insurance company before receiving medication or undergoing a medical procedure. The administration’s rules will require insurance companies working in federal programs to expedite the approval process and make decisions within 72 hours for urgent requests. Additionally, companies will be required to provide a specific reason for denial and publicly report denial metrics.

While the new regulations have been welcomed by patients, advocates, and researchers, many argue that the rules do not go far enough to address the magnitude of the issue. Aija Nemer-Aanerud, a healthcare campaign director for People’s Action Institute, expressed appreciation for the administration’s actions but highlighted that the rules still allow insurance companies to profit from denying people care.

The newly finalized rules will impact approximately 105 million people who rely on Medicare, Medicaid, and individual insurance exchanges. However, there are concerns that the rules exclude coverage for the 158 million individuals who rely on employer-provided insurance. In addition, prior authorizations for medications are not covered by the new rules, though the federal government has expressed intentions to address this in the future.

Patients, providers, and advocates have voiced their frustration with the prior authorization process, arguing that insurance companies use it to delay and discourage patients from seeking necessary care. While insurance companies argue that prior authorization saves money by reducing unnecessary care, many individuals have had to navigate a difficult and time-consuming appeals process to access essential treatments.

The story of Carly Morton, a Medicare Advantage plan holder, exemplifies the challenges individuals face with prior authorizations. After numerous denials, she was forced to mount a public pressure campaign to secure coverage for a surgery to treat a rare condition. The complexity and toll of navigating the prior authorization process have left many individuals feeling overwhelmed and burdened by a system that should facilitate access to necessary medical care.

In conclusion, while the Biden administration’s rules on prior authorization represent a step in the right direction, there are concerns about the limitations and the exclusion of certain groups from the coverage. As the debate continues, individuals affected by these regulations hope for a more comprehensive approach to addressing the challenges posed by prior authorization in the healthcare system.