In part one of this article, we explored how artificial intelligence (AI) is reshaping prior authorization (PA) processes in healthcare. While AI promises efficiency and cost savings, its integration into insurance systems has introduced new challenges like inaccuracies, delays in care, and physicians’ decisions being overridden, to name a few.
But these issues don’t just impact patients and their communities; they have significant implications for attorneys handling cases involving insurance disputes and personal injury matters.
In the second part of the series, we’ll dive deeper into the real-world consequences of tight insurance controls, the risks of AI-driven decision-making, and how these factors impact patient outcomes. We’ll also share how Integrity Legal Nurse Consulting PDX can help you navigate these complexities, so you can advocate for your clients with the care they deserve.
The Human Costs of Tight Insurance Controls
PA, step therapy, and provider networks are processes healthcare insurers use to control costs. These systems were designed to ensure that medical services, therapies, and medications are clinically appropriate, medically necessary, and aligned with evidence-based guidelines.
But here’s the problem: Insurance companies increasingly rely on AI to automate PA decisions, often removing human oversight from the process. While this may sound efficient, it frequently creates more problems than it solves.
PA is intended to encourage adherence to established clinical guidelines, ensuring safer and more effective treatments. However, despite legislative and insurer efforts, physicians argue that PA causes treatment delays and has detrimental effects on patient outcomes, particularly for those with severe illnesses like inflammatory bowel disease, cardiac diseases, and bipolar disorder.
The American Medical Association (AMA) conducts an annual survey of 1,000 practicing physicians, which has revealed alarming issues with the PA process. Here’s what they found:
Delayed or Denied Care Leads to Harm
Prior authorization requires healthcare providers to obtain insurance approval before administering treatments or medications. While intended to ensure appropriate care, PA often results in:
Treatment delays: 94% of physicians report delays in care, with 78% noting that these delays lead to treatment abandonment, and 79% indicating that patients incur out-of-pocket expenses as a result. Additionally, 53% of physicians report impacts on a patient’s job performance due to these delays.
Serious bodily harm: 24% of physicians report adverse events, including hospitalizations, permanent injury, or even death, due to PA.
Increased costs: 48% of physicians report that some patients cannot wait for approval to begin treatment, which can mean that patients are often forced to seek more expensive care, such as emergency room visits.
To make matters worse, orthopedic surgeon Daniel Paull, MD, notes, “Prior authorization is not a guarantee of payment.” In some cases, an insurer may refuse to pay for pre-approved care or determine that a treatment was not medically necessary after it has already been given. In that case, Paull states, “There is limited recourse besides pleading with them to pay.”
For attorneys, these delays can be critical evidence in cases involving insurance disputes or personal injury claims. By analyzing your client’s medical records, Integrity Legal Nurse Consulting PDX can help you identify how insurance-imposed barriers impact your cases.
Step Therapy Can Lead to Ineffective Treatments
Step therapy, or “fail-first” therapy, requires patients to try lower-cost medications before switching to more expensive options. This practice can lead to:
Ineffective treatment: 69% of physicians report that step therapy restrictions result in ineffective initial treatments.
Higher long-term costs: Delaying effective care often leads to more extensive and costly treatments down the line.
In cases involving denied or delayed care, step therapy restrictions can be a key factor in demonstrating how insurers prioritized cost savings over patient well-being. Our future medical cost projections can help you quantify the financial and physical impact of these practices.
AI-Driven Decisions Introduce Bias and Delays
As discussed in part one, insurance companies increasingly rely on AI to automate PA decisions. While AI can streamline processes, it also introduces significant risks:
Algorithmic bias: AI may perpetuate healthcare biases by neglecting underrepresented populations or medical conditions. Since AI relies on existing data, insufficient or non-diverse information can lead to overlooked nuances. 35% of physicians report that PA criteria are rarely or never evidence-based, yet 62% do not appeal PA decisions because they feel it’s futile.
Delayed approvals: 73% of physicians reported increased PA denials over the past five years. Patients may become caught in a cycle of appeals and longer wait times, exacerbating their health issues and increasing costs in the long run.
For attorneys, AI-driven denials can be evidence of systemic failures in insurance decisions. Our chart review and analysis services can help you uncover patterns of bias or errors in AI-driven PA processes.
The Impact on Providers and Patient Relationships
Physicians and staff spend up to 12 hours per week on PA tasks, leading to:
Clinician burnout: 95% of physicians report increased burnout due to administrative burdens.
Less time for patient care: Over 50% of physicians participate in time-consuming peer-to-peer reviews with insurance representatives, often cutting into their direct patient care time. Some physicians indicate they were not communicating with an appropriately qualified peer during these reviews.
These burdens can lead to errors or oversights in patient care, which may be relevant in cases involving denied or delayed treatments. Our attorney-provider liaison services can help you navigate these complexities and clarify the role of insurance controls in your cases.
Erosion of trust between patients and providers: When patients experience delays or denials, they often blame their healthcare providers, not realizing the role of insurance companies. This erosion of trust can complicate cases, as patients may interpret delays as a lack of care.
How Integrity Legal Nurse Consulting PDX Can Help
At Integrity Legal Nurse Consulting PDX, we specialize in helping attorneys navigate the complexities of medical records, insurance controls, and healthcare systems. Here’s how we can support your cases:
Chart Review & Analysis: Identify how PA delays, step therapy, or AI-driven denials affect your cases.
Timeline of Events: Create a clear, compelling narrative that highlights the impact of insurance-imposed barriers.
Future Medical Cost Projections: Quantify the long-term financial impact of delayed or denied care.
Locating the Best Testifying Expert for Your Case: Locate and vet the best expert who can explain the role of insurance controls in your case.
Attorney-Provider Liaison Services: Facilitate communication between you and healthcare providers to clarify key issues.
Book a Free Consultation
Tight insurance controls and AI-driven decision-making are healthcare issues, but they’re also legal issues. Don’t allow confusing medical information to prevent you from pursuing what’s right. Partner with Integrity Legal Nurse Consulting PDX to build your most compelling cases and secure the best outcomes for your clients. Book a free consultation with one of our experts today.
Sources:
- Benefits of Prior Authorizations | National Library of Medicine
- What You Should Know About Provider Networks | Health Insurance Marketplace
- H.R.3173 – Improving Seniors’ Timely Access to Care Act of 2022 | Library of Congress
- Prior authorization reduction equals nearly 20 percent of overall volume | United Healthcare
- Delays Related to Prior Authorization in Inflammatory Bowel Disease | National Library of Medicine
- Burden with No Benefit: Prior Authorization in Congenital Cardiology | National Library of Medicine
- Unintended Impacts of a Medicaid Prior Authorization Policy on Access to Medications for Bipolar Illness | National Library of Medicine
- 2024 AMA prior authorization physician survey | American Medical Association
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