When Daniel was consumed in severe and inexplicable pain for months, his doctor prescribed an MRI. However, his health insurance company required him to approve the test as well before he took the procedure. When the insurance company refused prior approval, it began a long journey to diagnose and treat the cystic or cysts in his iconic column. For Daniel, it meant reliance on opioids amid more than a year of weakness, weight loss, suicide depression, and delayed diagnosis and treatment. And his repeated appeals to the rejected approval exhausted the small energy of energy he had.
While writing my upcoming book (about delays and denials in health insurance coverage), I found Daniel's tragic experiences to be far too common. Of the 1,340 people I surveyed, 36% experienced at least one coverage refusal, and in many cases they kept medical care out of reach. Previous permits are usually deployed by private health insurance companies, causing doctors and patients to anger. But now, thanks to the Trump administration, Medicare beneficiaries are also beginning to face these obstacles for care.
Private insurance companies typically deploy advance permits to limit low-value care and to keep healthcare costs down.
Starting next year, through the implementation of a wasteful and inappropriate service reduction (Wiser) model, the Centers for Medicare and Medicaid Services (CMS) will launch a pilot program that imports pre-approval processes into traditional Medicare plans in six states. The program uses artificial intelligence tools to determine whether these Medicare beneficiaries will receive the care their physicians need.
Private insurance companies typically deploy advance permits to limit low-value care and to keep healthcare costs down. Tactics were used sparingly early on, but now they are applied to most expensive drugs and almost all surgeries and procedures. Most previous approvals are ultimately approved, but they cause headaches and frustration between patients and doctors, and lead to distrust in the healthcare system. Advance permissions will result in delays and denials in health insurance. And the challenging process of denial is extremely burdensome, especially for those who are already struggling with severe or life-threatening health conditions.
To appeal for a denial of coverage, we need the advanced health insurance literacy and fortitude that most of us lack, especially during the health crisis. Coordinating between physicians and insurance companies can guide patients such as Daniel while potentially moving forward without treatment and experience overwhelming loss of sensation and autonomy amid this navigational anxiety. It's no wonder why so few patients choose to ultimately appeal. In fact, just 11.7% were appealed despite most appeals resulting in an initial reversal of 3.2 million rejections offered by the Medicare Advantage Plan in 2023.
Therefore, healthcare is hard-distributed to navigate the American maze of health insurance bureaucracy, not by a final refusal of coverage, but by accumulation of inconvenience from patients, especially from marginalized backgrounds. Perhaps not surprising, the use of prior approval is not only broad, but also has unfair effects. My research found that fewer wealthy patients are unlikely to complain, while sick patients and black and Hispanic Medicaid patients are unlikely to successfully complain.
Approximately 33 million Americans in Medicare's traditional service fee plans have managed to avoid these administrative burdens as these plans are rarely rare, including durable medical devices. Meanwhile, 99% of Medicare Advantage beneficiaries have prior permission requirements in their plans. However, the proposed changes under the Trump administration could lead to a similar deficit for enrollees who rely on traditional Medicare, leading to delays in care and forgiveness.
The reliance on AI for health insurance companies to handle their claims already faces legal challenges.
And don't forget that most Medicare beneficiaries are over 65 years old. The complexity of these health insurance processes is especially cumbersome, even if it is impossible, as older people tend to have lower health insurance literacy, more likely to face significant health challenges and often suffer from cognitive decline.
CMS Director Dr. Mehmet Oz claims the pilot program is intended to “shatter fraud, waste and abuse.” However, it will inevitably promote delayed care and attractive burden for seniors across the country. Similarly, it exacerbates the administrative burden of physicians who must submit prior permit documents, perform a “peer-to-peer” review of denials, and perform a “peer-to-peer” review on behalf of the patient. In fact, apart from simply fighting overprescriptions, the prior permission-related burden can actually lead to Underrated to avoid subsequent delays or denial of compensation.
Furthermore, the reliance on health insurance companies to rely on AI to handle claims (including beneficiaries of Medicare Advantage) already faces legal challenges. The lawsuits filed against UnitedHealth, Cigna, and Humana challenge the deployment of AI programs to determine the amount of coverage a patient needs, regardless of the treatment physician's recommendations. Despite court scrutiny, only a small number of patients (usually more favorable patients) have filed a complaint of refusal to these prior approvals. In other words, the high rate at which these refusals are reversed is as high as 90%, which could be an acceptable cost for insurers if the process rarely challenges the decision in the first place.
Daniel eventually received the spinal cord stimulation device, but through his long-term suffering he wondered if his supportive team of family and doctors advocating for access to care at each turn of the health insurance maze was not present. Applying managed healthcare tools to older people who may face cognitive decline and deterioration in physical health is a disaster recipe that makes too many health benefits illustrate. In countries as wealthy as the United States, there should be a risk of reading the inscriptions of older people as “dead in the deficit.”
