The “Hidden Crisis” of Coverage Denials

When insurance companies say "no" — whether through prior authorization requirements, step therapy programs, or nonmedical switching policies — covered patients find … well … they don't have the coverage they need. A new survey finds this "hidden health care crisis" hits tens of millions of Americans.

"The real crisis is among patients with chronic illnesses who tell us that insurance is worthless when their insurance providers withhold coverage of essential treatments prescribed by a doctor," said Stacey Worthy, executive director of Aimed Alliance and a founding member of the Doctor-Patient Rights Project, which recently commissioned a survey of insured Americans.

The survey, which can be read in full here, sought to understand the number of people affected by coverage denials for treatment of chronic or persistent illnesses or conditions.

According to the survey: 

  • Almost two out of three patients were denied coverage multiple times, and most had to wait more than a month before their insurance provider responded to a request for treatment.
  • Almost a third (29%) of patients initially denied coverage reported that their conditioned worsened, even after the insurer was persuaded to cover the treatment.
  • Thirty-four percent of patients who were denied coverage had to put off or forego treatment altogether. 

TMA worked diligently during the 2017 legislative session to limit insurance providers' role in treatment decisions in Texas. With the help of member-physicians who wrote letters and emails to their senators and representatives, as well as physician testimony, TMA helped pass into law Senate Bill 680 by Sen. Kelly Hancock (R-North Richland Hills), which further empowers physicians to override health plans' step therapy protocols. 

Also, check out the September issue of Texas Medicine, TMA's monthly magazine, for a hard look into prior authorizations, including independent review organizations and peer-to-peer conversations. Authorizations are designed to keep costs down, but Texas physicians tell TMA that in the past year or so, prior authorizations have become abusive.

Action, Sept. 1, 2017

Last Updated On

September 01, 2017

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