Insurers Pledge to Ease Controversial Prior Approvals for Medical Care

Facing regulatory crackdowns and intensifying criticism from patients and doctors, the nation’s biggest health insurers said on Friday that they would retreat from tactics that have delayed medical care and led at times to denials for necessary treatments.

For years, the widespread practice known as prior authorization has vexed patients who might not have been notified until the day of surgery whether a procedure would be covered by their insurance or if a prescription medicine would be denied for no clear reason.

Insurers often send unintelligible form letters, leaving patients to puzzle out the basis for the denial or what their next steps should be. Patients may delay or even abandon necessary medical care because they may not even be aware that they can appeal the decisions.

Lawmakers, regulators and public outrage have drawn attention to abuses of the system, leading to mounting calls for reforms. Insurers have also been the target of myriad lawsuits, some of which attributed patient deaths to those denials and delays. The murder of Brian Thompson, a UnitedHealthcare executive, last December renewed criticisms of the tactic, unleashing a barrage of complaints that the practice was deployed to avoid covering care.

“Prior authorization is a huge issue for people who are in managed care plans because it is one of the ways plans use to control their costs,” said David A. Lipschutz, co-director for the Center for Medicare Advocacy. He pointed to several studies showing that insurers may have inappropriately denied care, particularly in private Medicare plans.

Various reports from federal regulators and researchers show that the vast majority of appeals are successful.