"Even when you go through this laborious process of getting [claims] appealed, we actually win most of them, which tells you there's something wrong with the system."

Prior authorization requirements are intended to ensure that health care services are medically necessary by requiring approval before a service or other benefit will be covered. Medicare Advantage insurers typically use prior authorization, along with other tools, such as provider networks, to manage utilization and lower costs.

When patient care or treatment is warranted by a specific diagnosis, I wish insurers would just reimburse it without any hassle. That's not reality. Let's talk about insurance claim denials, how they're rising and harming patient care, and what we can do about it. That's kind of complicated.

Hospitals have experienced significant increases in insurance claim and prior authorization denials since 2019, potentially driven by insurers' use of AI tools for coverage decisions, according to a report by this Senate subcommittee.

It's hard to nail down exactly when insurance companies began implementing AI tools; they tend to be vague about internal automation processes. But multiple health care and tech leaders who spoke with Newsweek began noticing accelerated claims denials between 2019 and 2020.

A recent publication from Palmetto GBA highlights the fact that laboratory services are among the top service types found to make the highest number of billing errors.

Health insurance companies claim prior authorization saves money, but this time-wasting, care delaying tactic may actually add significant costs to the nation’s health system.

Financial challenges remain a significant concern, with 81% of leaders noting a direct impact on patients, Philips' report reveals.

From beckershospitalreview.com: Researchers at the Icahn School of Medicine at New York City-based Mount Sinai found that large language models were poor medical coders.

From Laboratory Economics: As part of a new 2023 directive, CMS is asking Medicare Administrative Contractors (MACs) to focus payment audits and claim reviews on providers and labs performing definitive drug testing.

In the digital age of healthcare, Electronic Health Records (EHRs) have revolutionized the way medical professionals manage patient information. However, amid the myriad benefits, there lurks a practice that has increasingly raised concerns: copy and paste.

Prior authorization policies enacted by many payers are increasingly moving beyond limited efforts to ensure appropriate utilization of testing and instead are being applied more broadly, often blocking or delaying access to necessary care.