Michigan Pushes Tougher Laws on Health Insurers: Denying Care Denied
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Amina Tollin, a patient diagnosed with polyneuropathy, experienced the effects of insurance prior authorization when Medicaid stopped paying for her essential blood infusion therapy. Prior authorization, a common insurance practice where approval is required before they will pay for certain treatments, has increased in recent years, reportedly causing delays and even denials of care. In response, more than two dozen states have considered legislation to minimize these delays and nine states have enacted new laws, including the creation of a “gold card” system in Texas to exempt physicians with a 90% approval rate from prior authorization requirements.
Amina Tollin’s Struggle with Prior Authorization
Amina Tollin, 40, was dependent on blood infusion therapy to manage her chronic nerve condition, polyneuropathy, until Medicaid stopped paying for the $18,000 monthly infusions. Stateline reports that her situation illustrates the growing problem of prior authorization in health insurance, causing harm to patients due to delays and denials.
States Reacting to Prior Authorization Issues
Over two dozen states have considered or enacted legislation to reduce prior authorization delays and denials. Dr. Jack Resneck, former president of the American Medical Association, hopes insurance companies will revise their stance on prior authorization, recognizing the harm to patients.
New Laws vs Insurance Companies
Insurance companies argue that prior authorization ensures only medically necessary treatments are used, protecting patients and lowering healthcare costs. Critics warn that new state laws may lack strong enforcement mechanisms, and insurance companies often find ways around regulation. Ron Howrigon, president of Fulcrum Strategies, warns that patients must remain vigilant with incorrect denials.
Influence of State Laws
State laws generally apply to state-regulated private health insurance plans and may not apply to Medicaid recipients or those covered by self-funded employer plans. The federal Centers for Medicare & Medicaid Services have finalized a rule to expedite prior authorization in government insurance programs, but the rule will only take effect in 2026.
Patients Suffering Due to Prior Authorization
Dr. Amy Faith Ho, an emergency medicine physician, sees many patients whose treatments are delayed or denied due to prior authorization. Prior authorization impacts patients with critical health conditions, with a 2023 study revealing that 1 in 5 cancer patients did not receive the care recommended because of the prior authorization process.
Strategies to Combat Prior Authorization Problem
States are tackling the issue by shortening decision times, reducing administrative burdens, increasing transparency, and insisting decisions are based on peer-reviewed clinical data. It may take time to determine which combination of strategies is most effective. In Texas, for example, a 2022 “gold card” law has had mixed results, with only 3% of physicians achieving gold card status, according to the Texas Medical Association.
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