Burden with No Benefit: Prior Authorization in Congenital Cardiology

Brian S. Marcus*, Neha Bansal, Joshua Saef, Christina Fink, Angira Patel, Katherine D. Shaffer, John E. Mayer, Jonathan N. Johnson, Kenneth Shaffer, Devyani Chowdhury

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

Prior authorization is a process that health insurance companies use to determine if a patient’s health insurance will cover certain medical treatments, procedures, or medications. Prior authorization requests are common in adult congenital and pediatric cardiology (ACPC) due to need for advanced diagnostics, complex procedures, disease-specific medications, and the heterogeneity of the ACPC population. Prior authorizations in ACPC are rarely denied, but nonetheless, they are often accompanied by significant administrative burden on clinical care teams and delays in patient care. Prior authorizations have been implicated in worsening care inequities. The prior authorization process is insurer specific with differences between commercial and public insurers. Prior authorization rejections were previously found to be more common for women, racial minorities, those with low education, and in low-income groups. Prior authorization unduly burdens routine diagnostics, routine interventional and surgical procedures, and routine cardiac specific medication use in the ACPC population. This manuscript highlights the burdens of prior authorization and advocates for the elimination of prior authorization for ACPC patients.

Original languageEnglish (US)
Pages (from-to)100-106
Number of pages7
JournalPediatric cardiology
Volume45
Issue number1
DOIs
StatePublished - Jan 2024

Keywords

  • Congenital heart disease
  • Pediatric cardiology
  • Prior authorization
  • Reform

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Pediatrics, Perinatology, and Child Health

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