When people get sick or need medical care, they worry about getting healthy — and staying well. What they shouldn’t have to worry about is whether they’re getting the best care possible or if their premium dollars are being wasted.
Health insurance providers are using innovative solutions to protect patients and be responsible stewards of their premium dollars. Our commitment is to ensure that patients get the best possible care at the lowest possible price. Three essential programs help us better serve patients and protect both their physical and financial health.
First, health insurance providers ensure the delivery of better, smarter care for patients through evidence-based medical management programs. Just like how doctors use scientific evidence to determine the safest, most-effective treatments, health insurance providers partner with doctors and nurses to help identify the clinical or alternative approaches that have better results, better outcomes and better efficiencies — based on the latest evidence. They then offer clinical decision support tools to encourage implementation. This helps ensure that patients receive the safest, most-effective care at the most affordable cost.
Second, health insurance providers work to protect patients from unnecessary or dangerous care by using prior authorization. Prior authorization is a pre-approval process where a doctor or hospital coordinates with an insurance provider before a patient receives certain tests, treatments or therapies. Typically, less than 15 percent of medical services need to be reviewed.
This collaboration ensures that medical care is safe and effective for that particular patient; is administered in the appropriate care setting by a qualified, licensed provider; and is provided with other support services that may be needed.
For example, prior authorization might be required before joint injections without clinical documentation showing a diagnosis of arthritis, or imaging tests with radiation for patients who may have already had high exposure to radiation from previous tests.
Insurance providers are working with doctors to improve the prior authorization process. America’s Health Insurance Plans, the American Medical Association and others have developed principles on finding the right solutions that balance safe, timely and affordable access to evidence-based care with more efficient and effective approaches that reduce administrative burdens for doctors.
Innovations such as web portals that can be used by providers to interact with multiple insurance providers serve as a one-stop solution that allow clinicians to exchange data with multiple health insurance providers in real time. These portals streamline and automate the prior authorization process by reducing the need for clinicians to call health insurance providers or use proprietary portals, allowing them instead to access a network of health insurance providers in one place. These efforts are critical, but we need to work together on accelerating progress.
Third, but no less important, insurance providers protect consumers and eliminate waste by stopping criminal fraud. The Federal Bureau of Investigation estimates that health care fraud costs American taxpayers as much as $230 billion a year. By eliminating fraud, we can lower health care costs significantly.
Many health insurance providers have established their own designated investigation units comprised of highly trained professionals who employ sophisticated analytics that indicate when an investigation is warranted — to prevent, detect and remedy fraudulent and abusive conduct. When they find criminal activity, they work closely with law enforcement — local police, state police, the FBI and the Drug Enforcement Administration — to stop fraud and protect the American people. This work helps ensure that the care paid for is legal and warranted and, more importantly, protects consumers and patients from both physical and financial harm.
In addition to this three-pronged approach, we are collaborating with doctors and hospitals in other ways to save money and improve care. We are working together to reduce out-of-control costs for prescription drugs. We are working together to improve provider directories and consumer information about doctors. And we are developing standards for how we exchange information electronically and how we measure performance. By agreeing on standards, we can help doctors spend more time with their patients as we make good use of technology to improve the flow of information.
Health insurance providers don’t just pay medical bills — we’re partners, dedicated to better health and well-being for consumers. We are committed to helping patients get better when they’re sick and stay healthy when they’re well. It’s why we work together with doctors, nurses and hospitals to break down barriers and find real solutions, so that patients get the care they need, when they need it, without hassle.
Matt Eyles is president and CEO of America’s Health Insurance Plans, the national trade association representing the health insurance community that serves millions of Americans.
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