A study conducted in 2023 by the Milliman group found that removing optimization reviews, or “prior authorizations” as they are known in the medical community, could result in a nearly $2,800 a year premium increase for a family of four.
We know these reviews can feel frustrating at times if you are a patient. You go to the doctor and he or she prescribes you a medication or orders a test, but Medicare or your insurer steps in and says they need to review.
While it may not seem like it in the moment, what is happening is your insurer is collaborating with your doctor to make sure you are getting the most appropriate, safe, and affordable care.
They check to make sure the doctor has not unintentionally prescribed a drug with high out-of-pocket costs if a generic is available.
They make sure the doctor did not inadvertently order lab tests at an out-of-network facility that will result in a large surprise bill.
They make sure the doctor did not accidentally prescribe a medication that would result in a dangerous or adverse event with a separate pre-existing condition.
These reviews bring down costs and enhance safety for patients.
Everyone agrees that people should get the care they need without unnecessary delay.
Everyone also agrees that insurance premiums should be as low as possible so that people can afford the care they need.
To achieve these goals, prior authorizations must remain in place and must be done efficiently.
Simply doing away with prior authorizations, or establishing unrealistic turnaround times, will stick families with a $2,800 bill many cannot afford.
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