Perspective: Addressing Commercial Health Plan Abuses to Protect Patients and Providers

Our country is ready, eager and hopeful this year for at least a partial return to the pre-COVID-19 world. Everyone has a role to play in getting there.

The women and men of America’s hospitals and health systems have fought each day for the past year to provide care to patients and protect their neighbors and communities. We have called on all commercial health insurers — more than once — to proactively step up and do more to ease the burdens on our nation’s doctors and nurses and ensure access to care for patients.

The AHA recently released a white paper that examined commercial health insurance practices that contribute to burnout in the clinical workforce and make it more difficult for some Americans to access the care they need.

These practices pre-date COVID-19, but the pandemic has brought new pressure on the need to address the problems they cause.

Unfortunately, some commercial health insurers chose to treat this past year as “business as usual.” In the face of the most serious public health threat in a century, several health insurers ramped up such onerous policies as denials for emergency services, denials for early sepsis interventions, questionable lab reporting requirements, and the abuse of utilization management tools to delay and deny payment.

On that last point, excessive prior authorization requirements, coupled with prolonged health plan responses, deny needed treatment and are a major source of frustration and burnout for many clinicians. Prior authorization is a practice in dire need of streamlining.

Our report highlights the adverse effects of the rise in prior authorization and inappropriate reimbursement delays and denials. In fact, one hospital system reported spending $11 million annually complying with health plan prior authorization requirements alone.

This is not the road to recovery for our patients or our health care system. Caregivers need immediate relief from these excessive burdens so they can focus their attention where it is needed most — caring for patients and saving lives.

As we rebuild our health care system, we have identified a number of important improvements that better serve patients and protect clinicians from burdensome health insurance practices that take them away from patient care.

These include: 24/7 availability of health plan staff to review prior authorization requests; streamlined processes for submitting prior authorization requests and receiving responses; expedited response timelines so patients do not wait unnecessarily for coverage to be approved; and financial penalties on health plans for excessive rates of inappropriate delays or denials.

We’ve shared these and other recommendations with Congress and policymakers, and we strongly urge insurers to take action on these important issues.

In addition, we have urged insurers to help free up beds desperately needed by COVID-19 patients by avoiding delays in transitioning patients from general acute-care hospitals to post-acute care and other clinically appropriate settings.

These are extraordinary times. As we have said since the start of the pandemic, we are all in this together. That includes health insurers, who need to do their part to ensure fair coverage for patients and providers.