Gov JB Pritzker wants to ban ‘prior authorization.’ Here’s how it works.
Gov. JB Pritzker wants Illinois to be the first state in the nation to ban prior authorization for in-patient mental health care.
A bill Gov. JB Pritzker introduced in Springfield aims to ban “predatory insurance practices,” including a form of prior authorization.
That’s a policy where a patient needs to get approval from their health plan before filling a prescription or getting a medical service in order for it to be covered by insurance.
To learn more about prior authorization and its impact on patients, Reset spoke with UChicago Harris School of Public Policy assistant professor Zarek Brot-Goldberg and Countryside resident Jackie Covarrubias. Her father’s chemotherapy medication often gets denied by his insurance.
Below are a few questions and answers from the interview
What is prior authorization?
Brot-Goldberg: There are some things the health insurance company will cover. And other things they refuse to cover. Prior authorization is something in the middle. So, the insurer says in order for you to receive coverage, we need to explicitly authorize that coverage. This means your doctor will have to file a request on your behalf. If the insurer approves, then you’ll receive coverage. Otherwise, you pay out of pocket.
What has been your experience with prior authorization?
Covarrubias: In 2017, my dad got diagnosed with leukemia. My dad will call me frustrated saying, “Jackie, I need you to call so and so I can’t take it anymore. They’re declining my chemo medicine pills.” Without insurance, the pill costs about $4000 a month.
The insurance says they need to get authorization from the doctor, but my dad walks out of the doctor’s office and gets his medication prescribed, nothing changes. It’s the same chemo, same dose every time and they’ll just decline him. It’s always a surprise to us when they do it and how they do it.
Is banning prior authorization a solution?
Brot-Goldberg: I’m a little negative about trying to ban these tools completely. If you try to ban these tools to lower costs, what we’ve seen insurers do instead is try to shift costs onto patients using things like high deductible plans.
This interview has been edited for length and clarity.
You can listen to the full conversation above.
More From
Reset with Sasha-Ann Simons
Gov JB Pritzker wants to ban ‘prior authorization.’ Here’s how it works.
Gov. JB Pritzker wants Illinois to be the first state in the nation to ban prior authorization for in-patient mental health care.
A bill Gov. JB Pritzker introduced in Springfield aims to ban “predatory insurance practices,” including a form of prior authorization.
That’s a policy where a patient needs to get approval from their health plan before filling a prescription or getting a medical service in order for it to be covered by insurance.
To learn more about prior authorization and its impact on patients, Reset spoke with UChicago Harris School of Public Policy assistant professor Zarek Brot-Goldberg and Countryside resident Jackie Covarrubias. Her father’s chemotherapy medication often gets denied by his insurance.
Below are a few questions and answers from the interview
What is prior authorization?
Brot-Goldberg: There are some things the health insurance company will cover. And other things they refuse to cover. Prior authorization is something in the middle. So, the insurer says in order for you to receive coverage, we need to explicitly authorize that coverage. This means your doctor will have to file a request on your behalf. If the insurer approves, then you’ll receive coverage. Otherwise, you pay out of pocket.
What has been your experience with prior authorization?
Covarrubias: In 2017, my dad got diagnosed with leukemia. My dad will call me frustrated saying, “Jackie, I need you to call so and so I can’t take it anymore. They’re declining my chemo medicine pills.” Without insurance, the pill costs about $4000 a month.
The insurance says they need to get authorization from the doctor, but my dad walks out of the doctor’s office and gets his medication prescribed, nothing changes. It’s the same chemo, same dose every time and they’ll just decline him. It’s always a surprise to us when they do it and how they do it.
Is banning prior authorization a solution?
Brot-Goldberg: I’m a little negative about trying to ban these tools completely. If you try to ban these tools to lower costs, what we’ve seen insurers do instead is try to shift costs onto patients using things like high deductible plans.
This interview has been edited for length and clarity.
You can listen to the full conversation above.
More From
Reset with Sasha-Ann Simons