Denials and prior authorizations: What it means and what needs to change with health insurance
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As the fallout of the killing of Brian Thompson continues to shakeout, Dr. Archelle Georgiou, the former chief medical officer for UnitedHealth Group from 1995 to 2007 and host of the podcast “Speak Up for Your Health,” spoke with Morning Edition host Cathy Wurzer about what people’s reactions reveal and what needs to change within the industry.
Georgiou says nothing from her past industry experience compares to what she is seeing today. In the ‘80s and ‘90s, as the insurance industry changed with HMOs and managed care, she says she saw vitriol then, but this time it’s different.
“I think that what complicates the picture today is that we’re also in the middle of a tragedy of a human being — of a father, of a son, of a colleague… That makes this situation even worse. I don't understand the reaction from other human beings,” Georgiou said.
Georgiou wants to make it clear that insurance denials can happen for a variety of reasons ranging from care that came from out-of-network providers to administrative issues like mistyping someone's insurance information. Medical necessity denials, however, are only made by clinicians.
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“The accrediting agencies have been in place for many, many years. It’s not an administrator. It’s not Brian Thompson who’s making medical necessity denials,” she said.
The requests go to a nurse and if it’s denied, depending on the exact reason, it either stays with a nurse or goes to a physician, Georgiou explained.
“So it’s important to remember that while they may not have the expertise to issue that denial, and they could be wrong — I'm not defending all of them — but I do want to emphasize that those denials, the medical necessity denials, are not made by, you know, a lay person,” she said.
During her time with the company in the early 2000s, she was involved with eliminating prior authorization reviews and denials. This was all reinstituted within the next 10 years due to the high and increasing cost of health care.
Georgiou hopes the industry takes a step back and looks seriously at this negative public reaction and re-examines whether prior authorization is the best practice.
Last year, UnitedHealthcare acknowledged the complexity and shared that they were going to reduce the number of services that require prior authorization. That reflection and change, she says, needs to go faster.
“The administrative burden of doing prior authorization review at the health insurance company level and at the provider level is extraordinary. Those resources could be reallocated to coordinating care for patients,” Georgiou says.
As a patient, if you get a denial by a medical insurer, Georgiou recommends getting your hands on a copy of the form and finding out what reason led to the denial, then appeal it through the insurer’s customer service.
According to Georgiou, statistics show 80 percent of medical necessity denials are ultimately appealed but just 10 or so percent of patients who get a rejection ever bother to go through the hassle.
After that appeal, if you still get a denial, you have the right to do an external appeal. If things escalate, she suggests going to the insurance commissioner and the attorney general’s office.
“And frankly, I know that it sounds extreme, but that's how you get action,” Georgiou said.
