Is congress listening to complaints about Medicare Advantage and pre-authorization?

From the response I received after yesterday’s post on my experience with Aetna’s Medicare Advantage program, I clearly touched a nerve with many readers and retirees.

In talking to a representative from Northwestern Medicine’s billing department that handles pre-authorizations, even if I make an appointment for an MRI six months ahead - which is often required - Northwestern Medicine doesn’t begin the process of contacting the Medicare Advantage private insurer for authorization until a week to ten days before the procedure.

Then the patient must wait for Aetna to carry out their procedures for determining pre-authorization.

If the procedure is denied by a for-profit insurer like Aetna, the denial can be appealed, often successfully. But the procedure or treatment is then delayed, with the potential for causing great medical harm to the elderly patient.

U.S. Senator Sherrod Brown, an Ohio Democrat, has called on fellow lawmakers to sign on to a joint letter asking the Centers for Medicare & Medicaid Services (CMS) to approve reforms to streamline the prior authorization process.

A bipartisan group of  61 U.S. senators and 233 members of the U.S. House of Representatives signed the June 22 letter.

The CMS has proposed a rule that would revamp prior authorization in Medicare Advantage plans.

The rule would require some insurers to respond to prior authorization requests more quickly, and to make requests more transparent.

Lawmakers also urged the CMS to approve a mechanism for “real-time” decisions on services and treatments that are routinely approved.

“We urge CMS to promptly finalize and implement these changes to increase transparency and improve the prior authorization process for patients, providers, and health plans,” the lawmakers wrote in the letter.

While this might be helpful, a fatal flaw in the current system is that the private insurer making the decision whether to authorize a procedure or treatment or not has a financial incentive to deny services.

To put it simply, private insurers who run the Medicare Advantage plans make money when services are denied.

As long as Medicare is dominated by for-profit insurance companies and becomes primarily a private insurance-based system, the needs of patients are not well served.

Many doctors will tell you that prior authorization hassles are hurting patient care.

Even the conservative American Medical Association says many patients give up on treatments due to delays in authorization.

One idea that the CMS proposal calls for is for some payers to move to fully electronic prior authorization by 2026.

Supporters say that would speed up the process.

But I fear this would only further remove medical decisions from the medical professional.

More algorithms replacing medical practitioners in directing patient care.