Prior authorization, sometimes called pre-certification, requires patients to endure their health insurers’ reviewing some medical treatments before deciding to cover them 鈥� or not. It’s a tool the plans say reins in costs and protects patients from unnecessary or ineffective medical treatment. Patients and doctors hate it.

But the new Centers for Medicare & Medicaid Services rules are limited.聽

So, doctors and hospitals are backing efforts by states to pass their own restrictions.

Last year, lawmakers in 29 states and District of Columbia considered some 90 bills to limit prior authorization requirements, , with notable victories in and The physicians association expects more bills this year.

Here in Missouri, Republican state introduced to exempt certain providers from always having to request authorization for care 鈥� a program often called “gold carding.” Stinnett said she was regularly frustrated by prior authorization hurdles in her work as a speech pathologist before joining the legislature in 2023.

“The stories all kind of look similar: It’s a big fight to get something done on the insurance side for approval,” Stinnett said. “Then sometimes, even after all of that fight,it feels like it may have not been worthwhile because some people then have a change at the beginning of the year with their insurance.”

That’s what happened to Christopher Marks, a 40-year-old truck driver from Kansas City, Mo.

Marks noticed an immediate improvement in his Type 2 diabetes symptoms last year when his doctor prescribed him the medication Mounjaro 鈥� which has a wholesale price of a month.But when his doctor followed the and increased his dose,Marks’s health insurer declined to pay for it.

Marks had a Cigna plan that he purchased on the federal Affordable Care Act marketplace, . After two appeals over a month and a half, Cigna agreed to cover the higher dose. A few months later, he said, when it was time to up his dose once more, he was denied again. By November, he decided it wasn’t worth sparring with Cigna anymore since the insurer was leaving at the start of this year. He decided to stay on the lower dose until his new insurance kicked in.

“That is beyond frustrating. People shouldn’t have to be like, 鈥業t’s not worth the fight to get my medical treatment,’” Marks said.

Cigna spokesperson Justine Sessions said the company uses prior authorizations for popular drugs such as Mounjaro to help ensure patients get the right medications and dosages.聽

“We strive to make authorizations quickly and correctly, but in Mr. Marks’s case, we fell short and we greatly regret the stress and frustration this caused,” she said.

Under Stinnett’s bill, a medical provider’s prior authorization requests during a six-month evaluation period would be reviewed by health plans. Providers whose requests were approved by a plan at least 90 percent of the time would be exempt from having to submit further prior authorization requests for patients on that plan for the next six months.

The exemptions would also apply to hospitals and other facilities that meet the threshold. They would have to continue hitting the 90 percent approval mark to keep the exemption.

Five states have passed some form of gold-carding program: Louisiana, Michigan, Texas, Vermont and West Virginia. The AMA is tracking active gold carding bills in 13 states, including Missouri.

A of 26 health insurance plans conducted by the industry trade group AHIP found that just over half of those plans had used a for medical services while about a fifth had done so for prescriptions.

Marks purchased insurance for this year on the federal marketplace from Blue Cross and Blue Shield of Kansas City. In January, his doctor re-prescribed the higher dose of Mounjaro that Cigna had declined to cover. A little over a week later, Marks said, his new insurance approved his prescription “without any fuss.”

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But when his doctor followed the and increased his dose of Mounjaro 鈥� a drug with a wholesale list price of a month 鈥� Marks’ health insurer declined to pay for it.

Marks had Cigna insurance that he purchased on the federal health insurance marketplace, . After two appeals over a month and a half, Cigna agreed to cover the higher dose. A few months later, he said, when it was time to up his dose once more, he was denied again. By November, he decided it wasn’t worth sparring with Cigna anymore since the insurer was leaving at the start of this year. He decided to stay on the lower dose until his new insurance kicked in.

“That is beyond frustrating. People shouldn’t have to be like, 鈥業t’s not worth the fight to get my medical treatment,’” Marks said.

The process Marks encountered is called “prior authorization,” or sometimes “pre-certification,” a tool insurers say they use to rein in costs and protect patients from unnecessary or ineffective medical treatment. But the practice has prompted backlash from patients like Marks, as well as groups representing medical professionals and hospitals that say prior authorization can interfere with treatment, cause medical provider burnout, and .

In January, the Biden administration announced new rules to streamline the process for patients with certain health plans, after attempts stalled out in Congress, including a in 2022. But states are considering prior authorization bills that go even further. Last year, lawmakers in 29 states and Washington, D.C., considered some 90 bills to limit prior authorization requirements, , with notable victories in and The physicians association expects more bills this year, many with provisions spelled out in the group drafted.

In 2018, health insurers signed a with various medical facility and provider groups that broadly laid out areas for improving the prior authorization process. But the lack of progress since then has shown the need for legislative action, said , past president of the AMA and a current trustee.

“They have not lived up to their promises,” Resneck said.

Resneck, a California dermatologist, emphasized pending bills in , , , , and that include several policies backed by the AMA, including quicker response times, requirements for public reporting of insurers’ prior authorization determinations, and programs to reduce the volume of requests, sometimes called “gold carding.” Legislation has come from both Democratic and Republican lawmakers, and some is bipartisan, .

In Missouri, by Republican state Rep. aims to establish one of those gold carding programs for treatment and prescriptions. Stinnett said she regularly was frustrated by prior authorization hurdles in her work as a speech pathologist before joining the legislature in 2023.

“The stories all kind of look similar: It’s a big fight to get something done on the insurance side for approval,” Stinnett said. “Then sometimes, even after all of that fight, it feels like it may have not been worthwhile because some people then have a change at the beginning of the year with their insurance.”

Under her bill, a medical provider’s prior authorization requests during a six-month evaluation period would be reviewed. After that period, providers whose requests were approved at least 90% of the time would be exempt from having to submit requests for the next six months. The exemptions would also apply to facilities that meet that threshold. Then, she said, they would need to continue meeting the threshold to keep the “luxury” of the exemption.

Five states have passed some form of gold carding program: Louisiana, Michigan, Texas, Vermont, and West Virginia. The AMA is tracking active gold carding bills in 13 states, including Missouri.

A of 26 health insurance plans conducted by the industry trade group AHIP found that just over half of those plans had used a for medical services while about a fifth had done so for prescriptions. They gave mixed reviews: 23% said patient safety improved or stayed the same, while 20% said the practice increased costs without improving quality.

The new federal finalized by the Centers for Medicare & Medicaid Services stop short of gold carding and don’t address prior authorizations for prescription drugs, like Marks’ Mounjaro prescription. Beginning in 2026, the new rules establish response time frames and public reporting requirements 鈥� and ultimately will mandate an electronic process 鈥� for some insurers participating in federal programs, such as Medicare Advantage or the health insurance marketplace. Manual submissions accounted for 39% of prior authorization requests for prescriptions and 60% of those for medical services, according to the 2022 insurance survey.

In Missouri, state and national organizations representing doctors, nurses, social workers, and hospitals, among others, back Stinnett’s bill. Opposition to the plan comes largely from pharmacy benefit managers and the insurance industry, including the company whose prior authorization process Marks navigated last year. A Cigna Healthcare executive saying the company’s experience showed gold card policies “increase inappropriate care and costs.”

The , which represents dozens of employers that purchase health insurance for employees, also opposes the bill. Members of the coalition include financial services firm Edward Jones, coal company Peabody Energy, and aviation giant Boeing, as well as several public school districts and the St. Louis city and county governments.

Louise Probst, the coalition’s executive director, said the prior authorization process has issues but that the coalition would prefer that a solution come from insurers and providers rather than a new state law.

“The reason I hate to see things just set in stone is that you lose the flexibility and the nuance that could be helpful to patients,” Probst said.

On the other side of the state, Marks purchased insurance for this year on the federal marketplace from Blue Cross and Blue Shield of Kansas City. In January, his doctor re-prescribed the higher dose of Mounjaro that Cigna had declined to cover. A little over a week later, Marks said, his new insurance approved the higher dose “without any fuss.”

Cigna spokesperson Justine Sessions said the company uses prior authorizations for popular drugs such as Mounjaro to help ensure patients get the right medications and dosages.

“We strive to make authorizations quickly and correctly, but in Mr. Marks’ case, we fell short and we greatly regret the stress and frustration this caused,” she said. “We are reviewing this case and identifying opportunities for improvement to ensure this does not happen in the future.”

Marks’ aim with this higher dose of Mounjaro is to get off his other diabetes medications. He particularly hopes to stop taking insulin, which for him requires multiple injections a day and carries a risk of from low blood sugar.

“I don’t really use the word 鈥榣ife-changing,’ but it kind of is,” Marks said. “Getting off insulin would be great.”

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“When a doctor says a patient needs a procedure, it is essential that it happens in a timely manner,” Health and Human Services Secretary Xavier Becerra said in . “Too many Americans are left in limbo, waiting for approval from their insurance company.”聽

Sometimes called pre-authorization or pre-certification, prior authorization requires patients and their doctors to seek approval from insurers before proceeding with a treatment, test or medication. Insurer payment is often contingent upon obtaining prior authorization, which may be demanded for everything from expensive cancer care to prescription refills.

Elizabeth Spencer, 71, of Lebanon, Tenn., said her Medicare Advantage plan requires her to get preapproval for continuous glucose monitoring supplies every 90 days. Spencer was diagnosed with Type 1 diabetes when she was 12 and estimated that she spends an hour every week on prior authorization requirements.聽

“I have to get a new prior authorization every time I am about to run out of supplies,” she said. “What part of that makes sense to anyone with half a brain?”

As Spencer’s experience shows, the process can be confusing and lengthy. Denials are common and appeals are often difficult to navigate. Doctors say some while waiting for an insurer’s permission for care.

Beginning in 2027, the Centers for Medicare and Medicaid Services will . They’ll have to respond to expedited prior authorization requests within 72 hours and to standard requests within seven days.

Insurers affected by the rule also must provide a specific reason for denying prior authorization requests and will be required to publicly report prior authorization data annually on their websites, among other changes.

But the new rule goes only so far, affecting just insurers doing business in federal programs, such as Medicare Advantage and Obamacare exchanges. Notably, it doesn’t cover insurance that some 158 million Americans get through their jobs 鈥� the most common kind of coverage in the United States. 聽

素人色情片surveys show that “this population has problems with prior authorization almost as much as those with [Affordable Care Act] marketplace, Medicaid and Medicare” coverage, said Kaye Pestaina, director of KFF’s Program on Patient and Consumer Protection.

“So I imagine there will still be calls for changes and transparency for these plans, mostly regulated by the Department of Labor,” she said.

The new rule also doesn’t cover prior authorization for prescription drugs, Pestaina added. CMS has indicated it will deal with that issue separately.聽

In the past year, 素人色情片Health News has heard from hundreds of patients who’ve had to endure insurance preapprovals for care. While originally promoted as a way to make the health-care system more efficient by eliminating unnecessary or duplicative treatment, prior authorization is now widely unpopular among doctors and patients.

“Family physicians know firsthand how prior authorizations divert valuable time and resources away from direct patient care,” Steven Furr, president of the American Academy of Family Physicians, said in a statement yesterday. “We also know that these types of administrative requirements are driving physicians away from the workforce and worsening physician shortages.”

Furr said the new rule “marks significant progress,” adding: “We need congressional action to cement this vital progress.”聽

Although the new rule doesn’t apply to all of their plans, some insurance companies have taken steps to improve prior authorization for all of their customers, in anticipation of the CMS crackdown. AHIP, an industry trade group formerly called America’s Health Insurance Plans, said the new federal rule is a “step in the right direction.”

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They all have something in common, aside from a nightmare diagnosis. Their insurance companies, at some point, denied doctor-recommended care through a process called prior authorization 鈥� a set of rules, unique to every health insurance plan, requiring preapproval for some tests, procedures and prescriptions. Sometimes it’s called preauthorization; sometimes precertification. Regardless, prior authorization is almost universally despised by doctors and patients.聽

In 2021, Medicare Advantage insurers processed an average of for every enrolled patient.

Legislation to regulate prior authorization for Advantage patients has strong support from lawmakers, but a bill hasn’t yet passed Congress. The Centers for Medicare & Medicaid Services is that could help millions more 鈥� including anyone enrolled in Medicare Advantage, Medicaid or an Obamacare marketplace policy.聽

The CMS rule, if implemented, would require some insurers to automate their prior authorization processes, respond to expedited prior authorization requests within 72 hours and standard requests within seven calendar days, and provide more information when they issue denials.聽

But CMS closed the public comment period on the rule 10 months ago and has said nothing since then about when, or if, it will be finalized. “There are no updates at this time,” a CMS spokesperson told me last Friday.

The in October urging CMS to act quickly. Jesse Ehrenfeld, president of the American Medical Association, told 素人色情片Health News on Monday that he hopes the proposed rule, if finalized, would “move the needle a little bit” 鈥� but he said it won’t be enough.聽

“I think we’re going to have to have regulatory relief from Congress,” said Ehrenfeld, an anesthesiologist. “Unfortunately, I hear from colleagues every week who are just at their wits’ end and it’s frustrating. I see it with my own parents.”

Insurers, he said, “continue to just harass patients, really, to improve their bottom line.”聽

David Allen, a spokesperson for AHIP, the insurance industry’s main lobbying group, argued health insurers use prior authorization selectively to ensure “the right care is delivered at the right time in the right setting鈥� and covered at a cost that patients can afford. That’s what prior authorization helps deliver.”

He added: “We make every effort to ease the burden on patients and providers.”

Meanwhile, patients across the country are stuck navigating a system rife with roadblocks, red tape and appeals.

“For them to take weeks 鈥� up to months 鈥� to provide an authorization is ridiculous,” said Marine Corps veteran Ron Winters, who for delaying his cancer treatment. “It doesn’t matter if it’s cancer or not.”

The proposed federal reforms wouldn’t apply to veterans such as Winters who receive their care through Veterans Affairs or the estimated 153 million Americans covered by private, employer-sponsored plans.聽

Even so, in anticipation of new regulations, many insurers already have started updating prior authorization processes for their private plans.

“It’s not clear to me that CMS is 鈥榣eading’ the way here, so to speak,” Robert Hartwig, director of the Center for Risk and Uncertainty Management at the Darla Moore School of Business at the University of South Carolina, said in an email. “I do think, however, that CMS sees that widespread adoption of electronic PA processes are on the near-horizon and is willing to use its heft as a major payer to expedite the transition.”

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“I listened to the insurance agent and, basically, he really promoted Medicare Advantage,” Timmins said. The agent described less expensive and broader coverage offered by the plans, which are funded largely by the government but administered by private insurance companies.

For Timmins, who is now 76, it made economic sense then to sign up. And his decision was great, for a while.

Then, three years ago, he noticed a lesion on his right earlobe.

“I have a family history of melanoma. And so, I was kind of tuned in to that and thinking about that,” Timmins said of the growth, which doctors later diagnosed as malignant melanoma. “It started to grow and started to become rather painful.”

Timmins, though, discovered that his enrollment in a Premera Blue Cross Medicare Advantage plan would mean a limited network of doctors and the potential need for preapproval, or prior authorization, from the insurer before getting care. The experience, he said, made getting care more difficult, and now he wants to switch back to traditional, government-administered Medicare.

But he can’t. And he’s not alone.

“I have very little control over my actual medical care,” he said, adding that he now advises friends not to sign up for the private plans. “I think that people are not understanding what Medicare Advantage is all about.”

Enrollment in Medicare Advantage plans has grown substantially in the past few decades, enticing more than half of all eligible people, primarily those 65 or older, with low premium costs and perks like dental and vision insurance. And as the private plans’ share of the Medicare patient pie has ballooned to 30.8 million people, so too have concerns about the insurers’ aggressive sales tactics and misleading coverage claims.

Enrollees, like Timmins, who sign on when they are healthy can find themselves trapped as they grow older and sicker.

“It’s one of those things that people might like them on the front end because of their low to zero premiums and if they are getting a couple of these extra benefits 鈥� the vision, dental, that kind of thing,” said Christine Huberty, a lead benefit specialist supervising attorney for the Greater Wisconsin Agency on Aging Resources.

“But it’s when they actually need to use it for these bigger issues,” Huberty said, “that’s when people realize, 鈥極h no, this isn’t going to help me at all.’”

Medicare pays private insurers a fixed amount per Medicare Advantage enrollee and in many cases also pays out bonuses, which the insurers can use to provide supplemental benefits. Huberty said those extra benefits work as an incentive to “get people to join the plan” but that the plans then “restrict the access to so many services and coverage for the bigger stuff.”

David Meyers, assistant professor of health services, policy, and practice at the Brown University School of Public Health, analyzed a decade of Medicare Advantage enrollment and found that 鈥� rural and urban 鈥� left their contract by the end of five years. Most of those enrollees switched to another Medicare Advantage plan rather than traditional Medicare.

In the study, Meyers and his co-authors muse that switching plans could be a positive sign of a free marketplace but that it could also signal “unmeasured discontent” with Medicare Advantage.

“The problem is that once you get into Medicare Advantage, if you have a couple of chronic conditions and you want to leave Medicare Advantage, even if Medicare Advantage isn’t meeting your needs, you might not have any ability to switch back to traditional Medicare,” Meyers said.

Traditional Medicare can be too expensive for beneficiaries switching back from Medicare Advantage, he said. In traditional Medicare, enrollees pay a monthly premium and, after reaching a deductible, in most cases are expected to pay 20% of the cost of each nonhospital service or item they use. And there is no limit on how much an enrollee may have to pay as part of that 20% coinsurance if they end up using a lot of care, Meyers said.

To limit what they spend out-of-pocket, traditional Medicare enrollees typically sign up for supplemental insurance, such as employer coverage or a private Medigap policy. If they are low-income, Medicaid may provide that supplemental coverage.

But, Meyers said, there’s a catch: While beneficiaries who enrolled first in traditional Medicare are guaranteed to qualify for a Medigap policy without pricing based on their medical history, Medigap insurers can deny coverage to beneficiaries transferring from Medicare Advantage plans or base their prices on medical underwriting.

Only four states 鈥� Connecticut, Maine, Massachusetts, and New York 鈥� prohibit insurers from denying a Medigap policy if the enrollee has preexisting conditions such as diabetes or heart disease.

Paul Ginsburg is a former commissioner on the Medicare Payment Advisory Commission, also known as MedPAC. It’s a legislative branch agency that advises Congress on the Medicare program. He said the inability of enrollees to easily switch between Medicare Advantage and traditional Medicare during open enrollment periods is “a real concern in our system; it shouldn’t be that way.”

The federal government offers specific enrollment periods every year for switching plans. During Medicare’s open enrollment period, from Oct. 15 to Dec. 7, enrollees can switch out of their private plans to traditional, government-administered Medicare.

Medicare Advantage enrollees can also switch plans or transfer to traditional Medicare during another open enrollment period, from .

“There are a lot of people that say, 鈥楬ey, I’d love to come back, but I can’t get Medigap anymore, or I’ll have to just pay a lot more,’” said Ginsburg, who is now a professor of health policy at the University of Southern California.

Timmins is one of those people. The retired veterinarian lives in a rural community on Whidbey Island just north of Seattle. It’s a rugged, idyllic landscape and a popular place for second homes, hiking, and the arts. But it’s also a bit remote.

While it’s typically harder to find doctors in rural areas, Timmins said he believes his Premera Blue Cross plan made it more challenging to get care for a variety of reasons, including the difficulty of finding and getting in to see specialists.

Nearly half of Medicare Advantage plan directories contained inaccurate information on what providers were available, according to the . Beginning in 2024, new or expanding Medicare Advantage plans with federal network expectations or their applications could be denied.

Amanda Lansford, a Premera Blue Cross spokesperson, declined to comment on Timmins’ case. She said the plan meets federal network adequacy requirements as well as travel time and distance standards “to ensure members are not experiencing undue burdens when seeking care.”

Traditional Medicare allows beneficiaries to go to in the U.S., and in most cases enrollees do not need approval to get services.

Timmins, who recently finished immunotherapy, said he doesn’t think he would be approved for a Medigap policy, “because of my health issue.” And if he were to get into one, Timmins said, it would likely be too expensive.

For now, Timmins said, he is staying with his Medicare Advantage plan.

“I’m getting older. More stuff is going to happen.”

There is also a chance, Timmins said, that his cancer could resurface: “I’m very aware of my mortality.”

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That’s because, after 素人色情片Health News sent questions to Nix’s insurance company, Blue Cross Blue Shield of Illinois, it retroactively approved $36,000 worth of treatments she thought she owed. Even better, she also learned she would qualify for the infusions moving forward.

Good news all around 鈥� except it didn’t last for long. After all, this is the U.S. health care system, where even patients with good insurance aren’t guaranteed affordable care.

To recap: For more than a decade, Nix, of Statesville, North Carolina, has suffered from autoimmune diseases, chronic pain, and fatigue, as well as a condition called trigeminal neuralgia, which is marked by bouts of electric shock-like pain that’s so intense it’s commonly known as the “.”

“It is a pain that sends me to my knees,” Nix said in October. “My entire family’s life is controlled by the betrayal of my body. We haven’t lived normally in 10 years.”

Late in 2022, Nix started receiving intravenous immunoglobulin infusions to treat her diseases. She started walking two miles a day with her service dog. She could picture herself celebrating, free from pain, at her daughter’s summer 2024 wedding.

“I was so hopeful,” she said.

But a few months after starting those infusions, she found out that her insurance company wouldn’t cover their cost anymore. That’s when she started “raising Cain about it” on Instagram and Facebook.

You probably know someone like Sally Nix 鈥� someone with a chronic or life-threatening illness whose doctor says they need a drug, procedure, or scan, and whose insurance company has replied: No.

Prior authorization was conceived decades ago to rein in health care costs by eliminating duplicative and ineffective treatment. Not only does overtreatment waste every year, but it also potentially harms patients.

However, critics worry that prior authorization has now become a way for health insurance companies to save money, sometimes at the expense of patients’ lives. 素人色情片Health News has heard from hundreds of people in the past year relating their prior authorization horror stories.

When we first met Nix, she was battling her insurance company to regain authorization for her infusions. She’d been forced to pause her treatments, unable to afford $13,000 out-of-pocket for each infusion.

Finally, it seemed like months of her hard work had paid off. In July, Nix was told by staff at both her doctor’s office and her hospital that Blue Cross Blue Shield of Illinois would allow her to restart treatment. Her balance was marked “paid” and disappeared from the insurer’s online portal.

But the day after the 素人色情片Health News story was published, Nix said, she learned the message had changed. After restarting treatment, she received a letter from the insurer saying her diagnoses didn’t actually qualify her for the infusions. It felt like health insurance whiplash.

“They’re robbing me of my life,” she said. “They’re robbing me of so much, all because of profit.”

Dave Van de Walle, a spokesperson for Blue Cross Blue Shield of Illinois, said the company would not discuss individual patients’ cases.

“Prior authorization is often a requirement for certain treatments,” Van de Walle said in a written statement, “and BCBSIL administers benefits according to medical policy and the employer’s benefit.”

But Nix is a Southern woman of the “Steel Magnolia” variety. In other words, she’s not going down without a fight.

In September, she called out her insurance company’s tactics in a that has garnered more than 21,000 signatures. She has also filed complaints against her insurance company with the U.S. Department of Health and Human Services, U.S. Department of Labor, Illinois Department of Insurance, and Illinois attorney general.

Even so, Nix said, she feels defeated.

Not only is she still waiting for prior authorization to restart her immunoglobulin infusions, but her insurance company recently required Nix to secure preapproval for another treatment 鈥� routine numbing injections she has received for nearly 10 years to treat the nerve pain caused by trigeminal neuralgia.

“It is reprehensible what they’re doing. But they’re not only doing it to me,” said Nix, who is now reluctantly taking prescription opioids to ease her pain. “They’re doing it to other patients. And it’s got to stop.”

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“This is bad,” the 66-year-old Durant, Oklahoma, resident remembered his urologist saying. Winters braced for the fight of his life.

Little did he anticipate, however, that he wouldn’t be waging war only against cancer. He also was up against the Department of Veterans Affairs, which Winters blames for dragging its feet and setting up obstacles that have delayed his treatments.

Winters didn’t undergo cancer treatment at a VA facility. Instead, he sought care from a specialist through the Veterans Health Administration’s , established in 2018 to enhance veterans’ choices and reduce their wait times. But he said the prior authorization process was a prolonged nightmare.

“For them to take weeks 鈥� up to months 鈥� to provide an authorization is ridiculous,” Winters said. “It doesn’t matter if it’s cancer or not.”

After his initial diagnosis, Winters said, he waited four weeks for the VA to approve the procedure that allowed his urologic oncologist at the University of Texas Southwestern Medical Center in Dallas to remove some of the cancer. Then, when he finished chemotherapy in March, he was forced to wait another month while the VA considered approving surgery to remove his bladder. Even routine imaging scans that Winters needs every 90 days to track progress require preapproval.

In a written response, VA press secretary Terrence Hayes acknowledged that a “delay in care is never acceptable.” After 素人色情片Health News inquired about Winters’ case, the VA began working with him to get his ongoing care authorized.

“We will also urgently review this matter and take steps to ensure that it does not happen again,” Hayes told 素人色情片Health News.

Prior authorization isn’t unique to the VA. Most private and federal health insurance programs require patients to secure preapprovals for certain treatments, tests, or prescription medications. The process is intended to reduce spending and avoid unnecessary, ineffective, or duplicative care, although the degree to which companies and agencies .

Insurers argue prior authorization makes the U.S. health care system more efficient by cutting waste 鈥� theoretically a win for patients who may be harmed by excessive or futile treatment. But critics say prior authorization has become a tool that insurers use to restrict or delay expensive care. It’s an especially alarming issue for people diagnosed with cancer, for whom prompt treatment can mean the difference between life and death.

“I’m interested in value and affordability,” said Fumiko Chino, a member of the Affordability Working Group for the Memorial Sloan Kettering Cancer Center. But the way prior authorization is used now allows insurers to implement “denial by delay,” she said.

Cancer is one of the most expensive categories of disease to treat in the U.S., according to the . And, in 2019, patients spent more than $16 billion out-of-pocket on their cancer treatment, by the National Cancer Institute found.

To make matters worse, many cancer patients have had oncology care delayed because of prior authorization hurdles, with some facing delays of more than two weeks, according to research Chino and colleagues in October. Another recent study found that major in response to imaging requests, most often in endocrine and gastrointestinal cancer cases.

The federal government is designed to improve prior authorization for millions of people covered by Medicare, Medicaid, and federal marketplace plans. The reforms, if implemented, would shorten the period insurers are permitted to consider prior authorization requests and would also require companies to provide more information when they issue a denial.

In the meantime, patients 鈥� many of whom are facing the worst diagnosis of their lives 鈥� must navigate a system marked by roadblocks, red tape, and appeals.

“This is cruel and unusual,” said Chino, a radiation oncologist. A two-week delay could be deadly, and that it continues to happen is “unconscionable,” she said.

Chino’s research has also shown that prior authorization is directly related to increased anxiety among cancer patients, eroding their trust in the health care system and wasting both the provider’s and the patient’s time.

Leslie Fisk, 62, of New Smyrna Beach, Florida, was diagnosed in 2021 with lung and brain cancer. After seven rounds of chemotherapy last year, her insurance company denied radiation treatment recommended by her doctors, deeming it medically unnecessary.

“I remember losing my mind. I need this radiation for my lungs,” Fisk said. After fighting Florida Health Care Plans’ denial “tooth and nail,” Fisk said, the insurance company relented. The insurer did not respond to requests for comment.

Fisk called the whole process “horribly traumatic.”

“You have to navigate the most complicated system on the planet,” she said. “If you’re just sitting there waiting for them to take care of you, they won’t.”

A that patients who are covered by Medicaid appear to be particularly impacted by prior authorization, regardless of their health concerns. About 1 in 5 adults on Medicaid reported that their insurer had denied or delayed prior approval for a treatment, service, visit, or drug 鈥� double the rate of adults with Medicare.

“Consumers with prior authorization problems tend to face other insurance problems,” such as trouble finding an in-network provider or reaching the limit on covered services, the report noted. They are also “far more likely to experience serious health and financial consequences compared to people whose problems did not involve prior authorization.”

In some cases, patients are pushing back.

In November, that Cigna admitted to making an error when it denied coverage to a 47-year-old Tennessee woman as she prepared to undergo a double-lung transplant to treat lung cancer. In Michigan, a former health insurance that the company had “crossed the line” in denying treatment for a man with lymphoma. And Blue Cross and Blue Shield of Louisiana “met its match” when the company denied a Texas trial lawyer’s cancer treatment, in November.

Countless others have turned to social media to shame their health insurance companies into approving prior authorization requests. Legislation has been introduced in 鈥� from California to North Carolina 鈥� to address the problem.

Back in Oklahoma, Ron Winters is still fighting. According to his wife, Teresa, the surgeon said if Ron could have undergone his operation sooner, they might have avoided removing his bladder.

In many ways, his story echoes the from nearly a decade ago, in which veterans across the country were languishing 鈥� some even dying 鈥� as they waited for care.

In 2014, for example, on veteran Thomas Breen, who was kept waiting for months to be seen by a doctor at the VA in Phoenix. He died of stage 4 bladder cancer before the appointment was scheduled.

Winters’ cancer has spread to his lungs. His diagnosis has advanced to stage 4.

“Really, nothing has changed,” Teresa Winters said. “The VA’s processes are still broken.”

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But among doctors and hospitals, it’s a different story.

The Health 202 is a coproduction of The Washington Post and 素人色情片Health News.

Across the country, provider grumbling about claim denials and onerous preapproval requirements by Advantage plans is crescendoing. Some hospitals and physician practices are so fed up they’re refusing to accept the plans 鈥� even big ones like those offered by UnitedHealthcare and Humana.

“The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents the for-profit hospital sector.

Last week, the industry’s largest lobbying group, the American Hospital Association, to the Centers for Medicare and Medicaid Services warning that some insurers seem intent on circumventing new rules put in place by the Biden administration aimed at reining in some prior authorization and claim denials.

It isn’t like we’ve never seen disputes between insurers and providers before, especially in negotiations with employer-sponsored plans.

But the focus now on Medicare Advantage “seems different,” said David Lipschutz, associate director and senior policy attorney for the Center for Medicare Advocacy, who says hospitals and doctors are becoming “much more vocal” about their frustrations with some of the insurers’ cost-control efforts.

for example, has threatened that all of its nine hospitals, along with its clinics and physician groups, will cut ties with Advantage plans offered by and beginning in January unless they can come to terms.

The plans “routinely deny or delay approval or payment for medical care recommended by your physician,” the system wrote in a message to patients posted on its website.

The system’s medical group, with nearly 1,500 physicians and other providers, network in September.

And in San Diego, more than 30,000 people are looking for new doctors after two large medical groups affiliated with Scripps Health said with any Medicare Advantage insurers. Revenue “is not sufficient to cover the cost of patient care we provide,” they said in a statement.

Lipschutz thinks providers are feeling emboldened by the Health and Human Services Department’s inspector general published last year that found some Advantage plans have denied coverage for care that should have been provided under Medicare’s rules.

The Biden administration’s new rules, set to take effect in January, are in part a response to the OIG report. Enrollment for Medicare Advantage plans, traditional Medicare coverage and stand-alone Medicare drug plans

While the insurance industry likes to boast that a huge majority of Congress supports the plans, there’s , too.

Prior approval is a big point of friction. Virtually all Medicare Advantage enrollees are in plans that require the insurer to sign off in advance for at least some care, . Insurers say that process .

In 2021, for prior approval were submitted for Medicare Advantage enrollees, according to KFF, and over 2 million of them were denied. For the small minority of patients who appeal (11 percent), a whopping 82 percent won a full or partial overturning of the insurers’ decision.

To be sure, commercial plans covering people with job-based insurance or those who buy their own through the Affordable Care Act also engage in prior approval, and there’s lots of complaints about them, too.

The difference with Medicare, though, is that beneficiaries can choose the traditional, government-run program, in which prior approval and claim denials . Doctors and hospitals have plenty of gripes about how much traditional Medicare pays them, but from their point of view, they spend less time fighting over medical decisions.

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Nix has struggled with a combination of autoimmune diseases since 2011. Brain and spinal surgeries didn’t ease her symptoms. Nothing worked, she said, until she started late last year. Commonly called IVIG, the treatment bolsters her compromised immune system with healthy antibodies from other people’s blood plasma.

“IVIG turned out to be my great hope,” she said.

That’s why, when Nix’s health insurer started denying payment for the treatment, she turned to Facebook and Instagram to vent her outrage.

“I was raising Cain about it,” said Nix, 53, of Statesville, North Carolina, who said she was forced to pause treatment because she couldn’t afford to pay more than $13,000 out of pocket every four weeks. “There are times when you simply must call out wrongdoings,” she wrote on Instagram. “This is one of those times.”

Prior authorization is a common cost-cutting tool used by health insurers that requires patients and doctors to secure approval before moving forward with many tests, procedures, and prescription medications. Insurers say the process helps them control costs by preventing medically unnecessary care. But patients say the often time-consuming and frustrating rules create hurdles that delay or deny access to the treatments they need. In some cases, delays and denials equal death, .

That’s why desperate patients like Nix 鈥� and even some physicians 鈥� say they have turned to publicly shaming insurance companies on social media to get tests, drugs, and treatments approved.

“Unfortunately, this has become a routine practice for us to resort to if we don’t get any headway,” said Shehzad Saeed, a pediatric gastroenterologist at Dayton’s Children’s Hospital in Ohio. In March, he , blaming Anthem for denying the biologic treatment his patient needed to ease her Crohn’s disease symptoms.

In July, Eunice Stallman, a psychiatrist based in Idaho, joined X, formerly known as Twitter, for the first time to , Zoey, had been denied prior authorization for a $225 pill she needs to take twice a day to shrink a large brain tumor. “This should not be how it’s done,” Stallman said.

The federal government has proposed ways to reform prior authorization that would require insurance companies to provide more transparency about denials and to speed up their response times. If finalized, those federal changes would be implemented in 2026. But even then, the rules would apply only to some categories of health insurance, including Medicare, Medicare Advantage, and Medicaid plans, but not employer-sponsored health plans. That means roughly wouldn’t benefit from the changes.

The 2010 Patient Protection and Affordable Care Act prohibits health insurance plans from denying or canceling coverage to patients due to their preexisting conditions. AHIP, an industry trade group formerly called America’s Health Insurance Plans, did not respond to a request for comment.

But some patient advocates and health policy experts question whether insurers are using prior authorization as “a possible loophole” to this prohibition, as a way of denying care to patients with the highest health care costs, explained Kaye Pestaina, a 素人色情片vice president and the co-director of its Program on Patient and Consumer Protections.

“They take in premiums and don’t pay claims. That’s how they make money,” said Linda Peeno, a health care consultant and retired Kentucky physician who was employed as a medical reviewer by Humana in the 1980s and . “They just delay and delay and delay until you die. And you’re absolutely helpless as a patient.”

But there’s reason to hope things may get marginally better. Some major insurers are to ease preapproval mandates for doctors and patients. And to rein in the use of prior authorization.

“Nobody is saying we should get rid of it entirely,” said Todd Askew, senior vice president for advocacy at the American Medical Association, in advance of the group’s . “But it needs to be right-sized, it needs to be simplified, it needs to be less friction between the patient and accessing their benefits.”

Customers are increasingly using social media to air their complaints across all industries, and companies are paying attention. Nearly two-thirds of complainants reported receiving some sort of response to their online post, according to the 2023 “National Consumer Rage Survey,” conducted by Customer Care Measurement & Consulting in collaboration with Arizona State University.

companies are better off engaging with unhappy customers offline, rather than responding to public social media posts. But many patients and doctors believe venting online is an effective strategy, though it remains unclear how often this tactic works in reversing prior authorization denials.

“It’s not even a joke. The fact that that’s how we’re trying to get these medications is just sad,” said Brad Constant, an inflammatory bowel disease specialist who has published research on prior authorization. that prior authorizations are associated with an increased likelihood that children with inflammatory bowel disease will be hospitalized.

Saeed said the day after he posted the picture of the skin rash, the case was marked for a peer-to-peer review, meaning the prior authorization denial would get a closer look by someone at the insurance company with a medical background. Eventually, the biologic medicine Saeed’s patient needed was approved.

Stallman, who is insured through her employer, said she and her husband were prepared to pay out of pocket if Blue Cross of Idaho didn’t reverse the denial for the drug Zoey needed.

Bret Rumbeck, a spokesperson for the insurer, said Zoey’s medication was approved on July 14 after the company consulted an outside specialist and obtained more information from Zoey’s doctor.

Stallman posted details about the ordeal online only after the insurer approved the drug, in part, she said, to prevent them from denying the treatment again when it comes up for a 90-day insurance review in October. “The power of the social media has been huge,” she said.

Nix had been insured by Blue Cross Blue Shield of Illinois through her husband’s employer for almost two decades. Dave Van de Walle, a spokesperson for the company, did not specifically address Nix’s case. But in a prepared statement, the company said it provides administrative services for many large employers who design and fund their own health insurance plans.

Nix said an “escalation specialist” from the insurance company reached out after she posted her complaints on social media, but the specialist couldn’t help.

Then, in July, after 素人色情片Health News contacted Blue Cross Blue Shield of Illinois, Nix logged in to the insurer’s online portal and found that $36,000 of her outstanding claims had been marked “paid.” No one from the company had contacted her to explain why or what had changed. She also said she was informed by her hospital that the insurer will no longer require her to obtain prior authorization before her infusions, which she restarted in late July.

“I’m thrilled,” she said. But “it just should never have happened this way.”

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As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.

But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.

“On at least four or five occasions, she called me up, hysterical,” Roux said.

Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.

Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”

Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.

Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.

Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.

So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.

“The prior authorization system should be completely done away with in physicians’ offices,” said , a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”

In December, the federal government that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be through March 13.

Although groups like AHIP, an industry trade group formerly called America’s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don’t go far enough.

“Seven days is still way too long,” said , a hematologist in Birmingham, Alabama, whose sickle cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “We need to move very quickly. We have to make decisions.”

Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests . In Michigan, insurers must , including the number of requests denied and appeals received. Other states have adopted or are , while in many places insurers regularly take four to six weeks for non-urgent appeals.

Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to in Pennsylvania, meant sick were more likely to be hospitalized, and blocked from getting treatment for opioid addiction.

In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.

Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.

Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.

Conlisk thought her mom’s case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn’t show on the day Conlisk was told it would. No one notified them the ride hadn’t been pre-authorized.

The time it takes to juggle a prior authorization request can also perpetuate racial disparities and disproportionately affect those with lower-paying, hourly jobs, said , a physician-scientist at the University of Virginia.

“When people ask for an example of structural racism in medicine, this is one that I give them,” McManus said. “It’s baked into the system.”

and her colleagues published in 2020 found that federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown. But she said that because lives in the South, they’d be the patients more likely to face this barrier.

Many of the denied claims are reversed if a patient appeals, according to . New data specific to Medicare Advantage plans found 82% of appeals resulted in fully or partially overturning the initial prior authorization denial, .

It’s not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.

“I lose hours of time that I really don’t have to argue 鈥� with someone who doesn’t even really know what I’m talking about,” said Kanter, the hematologist in Birmingham. “The people who are making these decisions are rarely in your field of medicine.”

Occasionally, she said, it’s more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and the patient more.

“It’s a terrible system,” she said.

A found that 9% of all in-network denials by Affordable Care Act plans on the federal exchange, healthcare.gov,聽were attributed to lack of prior authorization or referrals, but some companies are more likely to deny a claim for these reasons than others. In Texas, for example, the analysis found 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.

Facing scrutiny, some insurers are revising their prior authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years by eliminating the need for patients to obtain permission for some diagnostic procedures, like MRIs and CT scans, said company spokesperson Heather Soules. Health insurers have also adopted to speed up prior authorization decisions.

Meanwhile, most patients have no means of avoiding the burdensome process that has become a defining feature of American health care. But even those who have the time and energy to fight back may not get the outcome they hoped for.

When the ambulance never showed in July, Conlisk and her mother’s caregiver decided to drive the patient to the clinic in the caregiver’s car.

“She almost fell outside the office,” said Conlisk, who needed the assistance of five bystanders to move her mother safely into the clinic.

When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day, for two weeks leading up to the clinic visit, working to get prior authorization. Her efforts were unsuccessful. Once again, her mother’s caregiver drove her to the clinic himself.

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