The Insured Face Challenges In Every Part Of Healthcare

Healthcare nightmares exist everyday as insured is faced with the Prior Authorization disaster.

The insurance companies worry about profits, so they have unilaterally decided that one way to control surgeries and other expensive procedures is to require prior authorization to complete a procedure or surgery. Your doctor must get permission to do the surgery or procedure, meaning he or she must justify to non-medical insurance personnel why the procedure or surgery is needed. This can take days, weeks and in some cases months.

This is regardless of the type of insurance, be it Medicare, individual or group coverage. If it is Medicare, you are dealing with the government so it could take more time to get the approvals. Individual or group coverages face the same bottlenecks in getting the approvals. One must wonder how many deaths can be attributed to delays in getting the approvals necessary to complete the procedure or surgery required?

This is a national problem that needs addressing. I’m not sure where or who should address it but it needs to be reviewed and streamlined.

Under most state laws. The insurance companies have 7-14 days to approve or deny the request. They usually find ways to avoid the timeline requirement by claiming the timeline starts when they deem, they have enough information to grant or deny the request. Usually means more delays in approval or denial. The doctor’s office must go through hoops to get the information to the insurance company and that also adds to the delay. The real issue is insurance companies want to make more profit and by denying all requests they achieve that result. Many patients don’t get the procedure or treatment they need and the doctor’s office are stifled by the delays.

Consider in your business if you were faced with these kinds of delays, what would that do to your business? Personally, it would frustrate me and affect my business operationally.

I don’t think anyone group is to blame. The doctors could be part of the problem because some do procedures not marginally needed others are concerned about their patient’s health and probably believe what they want to do procedure which is best for that patient. On the other hand, the insurance company has a basic mistrust of all Doctors and are concerned

that the procedure might be unnecessary, but it appears that the insurance companies routinely reject each claim, so they don’t pay for procures not needed.

The issue to this blogger is the mistrust from the insurance company and perhaps the efficiency of the process. In other words, is it necessary or not. The insurance company errs on their side always stating the procedure isn’t necessary, whether it is or not. Partially because the doctor doesn’t provide proof of the need as requested by the insurance company. The other reason is profits. The more procedures the insurance denies, the more money they make.

That is the crux of the issue. Insurance profits versus medically necessary procedures. Please be aware I am not suggesting all insurance companies operate like this but many still do. The issue is the process takes too long, and some might not survive waiting for approval.

It’s tough on all sides of this issue and I would like to see some movement to streamline the process. This is just one man’s opinion.

I hope this information is useful and if anyone has questions, please contact me via phone or email and I will respond quickly.

Also, you may want to take a look at Medicare 2025 Information.

The Barend Agency Inc.

Len Barend, Broker

Cell:702-250-2200