Burden with No Benefit: Prior Authorization in Congenital Cardiology

Abstract

Prior authorization is a process that health insurance companies use to determine if a patient’s health insurance will cover certain medical treatments, procedures, or medications. Prior authorization requests are common in adult congenital and pediatric cardiology (ACPC) due to need for advanced diagnostics, complex procedures, disease-specific medications, and the heterogeneity of the ACPC population. Prior authorizations in ACPC are rarely denied, but nonetheless, they are often accompanied by significant administrative burden on clinical care teams and delays in patient care. Prior authorizations have been implicated in worsening care inequities. The prior authorization process is insurer specific with differences between commercial and public insurers. Prior authorization rejections were previously found to be more common for women, racial minorities, those with low education, and in low-income groups. Prior authorization unduly burdens routine diagnostics, routine interventional and surgical procedures, and routine cardiac specific medication use in the ACPC population. This manuscript highlights the burdens of prior authorization and advocates for the elimination of prior authorization for ACPC patients.

Large language models to help appeal denied radiotherapy services

“…1,2 Patients' physicians are permitted to appeal coverage denials through avenues the insurer stipulates, and which usually involve telephone conversations with insurer designees ("peer-to-peer" discussions) and formal appeal letters. Insurers assert that this practice adjudicates the best use of medical resources and protect patients from unnecessary medical interventions, but physicians across a spectrum of medical specialties argue that these practices delay patient care, 3,4 discriminate, 5,6 deter enrollment to and confound interpretation of clinical trials, 7,8 and burden physicians [9][10][11][12] with unnecessary clerical work and costs. 13 Cancer patients -whose lives might depend on multidisciplinary systemic, surgical, and radiotherapeutic treatments -are too familiar with insurer delays and denials.…”