![]() ![]() Patrick Pevoto, president of the Colorado Medical Society, said he understands the need for some checks on prescribing, since not all doctors have good intentions. ![]() “Independent studies show - and doctors agree - that differences in how care is provided to patients can lead to inappropriate, unnecessary and more costly medical treatments that can harm patients.”ĭr. That’s what prior authorization helps deliver,” he said in a statement. “Patients deserve the most effective, safest and most affordable care. Insurers have taken steps to speed it up, like moving to electronic processing and “gold carding,” where physicians with a track record of appropriate prescribing can skip some prior authorizations, he said. “If a member has a concern about a coverage decision, we always encourage them to take advantage of their rights to appeal.” Prior authorizationĭavid Allen, a spokesman for America’s Health Insurance Plans, said prior authorization is one way companies protect their customers from receiving care that isn’t safe or hasn’t been shown to work. “This is to ensure the therapies we cover for our members are safe, effective and evidence-based,” she said in a statement. Department of Labor, which regulates most employer-sponsored insurance plans, said they also intend to take a look. A congressional committee is investigating insurance giant Cigna after reports its doctors were spending an average of 1.2 seconds reviewing cases before denying care as not medically necessary. The idea is that insurers will flag wasteful and harmful treatments, and encourage patients to try out less-expensive options first.ĭoctors and patients have raised concerns about whether some companies are putting up unnecessary hurdles or rejecting claims out of hand, though. State and federal law gives insurance companies latitude to assess whether a drug or procedure is necessary before agreeing to pay for it, a process known as prior authorization. “To feel this helpless as a patient, even knowing how to navigate the system, has been a gut punch.” “My worry is this is just a means to deny me the medication,” he said. The medication, called Dupixent, costs about $52,000 a year, and also has helped with his asthma, Shaw said. The company refused to pay unless he got an endoscopy procedure examining his esophagus to check for a placebo effect, which is essentially unheard of, he said. Shaw, a pediatrician in Littleton, has dealt with insurance denials when trying to get drugs approved for his patients, but said Excellus BlueCross BlueShield’s delay in paying for his own treatment for eosinophilic esophagitis used a new tactic. Eric Shaw felt huge relief when he finally found a drug that stopped the allergic reaction that made it hard for him to swallow - and a significant blow when he learned his insurance company might not cover it. Digital Replica Edition Home Page Close Menuĭr. ![]()
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