WASHINGTON, D.C. – The Biden administration has announced new regulations aimed at curbing the practice of prior authorization by private health insurance companies. Prior authorization often leads to delayed care and opaque appeals processes for patients seeking medication or surgery.
Under the newly finalized rules, insurance companies working with federal programs will be required to expedite the approval process for urgent requests and make decisions within 72 hours. Additionally, these companies must provide a specific reason for any denial and publicly report denial metrics. However, these regulations will primarily go into effect in 2026.
While the new rules have been welcomed by patients, advocates, and researchers, some have expressed concerns about the limitations of these regulations. A healthcare campaign director stated that while the rules address the issue, they do not go far enough to address the larger problem of insurance companies profiting from denying people care.
It is estimated that these new rules will impact about 105 million people covered by Medicare, Medicaid, and individual insurance exchanges, leaving out the 158 million who rely on their employer’s insurance. Furthermore, the regulations do not cover prior authorizations for medications, although the federal government intends to address this in the future.
Despite arguments from insurance companies that prior authorization saves patients money by reducing unnecessary care, patients, providers, and advocates claim that it is often used to delay and discourage patients from seeking necessary care, even when it is urgently needed.
The article highlights the experiences of individuals who have faced challenges navigating the prior authorization process. It includes the story of a woman who had to mount a public campaign to get her insurance to cover surgery for a rare vascular condition. Additionally, it shares the story of a woman whose prior authorization requests for treatment have been repeatedly denied, leaving her in excruciating pain.
The new regulations aim to address the issues surrounding prior authorization, but concerns remain about the scope of these rules and their impact on the larger pool of privately insured Americans. Despite the limitations, the Biden administration’s efforts to reform the prior authorization process represent a significant step towards improving access to healthcare for millions of Americans.