Some insurance plans require doctors to seek prior authorization before commencing a specific treatment or intervention. This can cause significant delays in treatment and, in the case of treating opioid use disorder, may even result in preventable overdose or death.
What is opioid use disorder?
Opioid use disorder (OUD) is the term used to describe addiction and dependence on a narcotic opioid substance, whether legally prescribed or illicit, such as: [1]
In the United States, an estimated 2.1 million individuals currently experience an OUD, while opioid-related overdoses have been steadily increasing since the early 1990s. These figures are believed to be related to the increase in prescription opioids, which are used to treat severe pain, and the illicit production and sale of the synthetic opioid fentanyl. [1][2]
What is the usual treatment for opioid use disorder?
Treatment for an OUD often involves medically-assisted detoxification and maintenance medications including buprenorphine and methadone, along with psychological and psychosocial interventions. [1][3]
Coming off an opioid substance can cause severe withdrawal symptoms. In some cases, withdrawal can be severe and often leads to a relapse. Because of this, professional intervention is recommended, to provide support, monitoring, and treatment throughout the withdrawal and detox process. [1]
What is prior authorization?
Prior authorization, also referred to as pre-approval, is a requirement set by insurance companies. This states that, before commencing a specific type of treatment or intervention, healthcare providers must first submit written requests for the treatment to be approved. [4]
Legally, insurance providers can request for any treatment to be prior authorized, although this typically only applies to very expensive or second-line treatments. [5]
Insurance companies asking for prior authorization for OUD treatment can state a list of requirements to be agreed to before approving care. This is especially the case with buprenorphine, a commonly used medication in the treatment of OUD. Some of these requirements and qualifying criteria include: [5][6]
- Regular or random urine drug tests
- Mandatory counseling or engagement in 12-step programs
- Regular pill counts
- Limited daily dosage
Doctors are required to fill in paperwork to be sent to and approved by insurance companies before they can commence treatment. As buprenorphine and other OUD medications are often first-line treatments, potentially life-saving, and often inexpensive, many professionals believe this process to be based on stigma and cost control, rather than patient care. [4][5]
What is the impact of prior authorization on treatment?
The opioid epidemic has resulted in increasing numbers of people experiencing OUDs and fatal overdoses from opioids. From 2020 to 2021, 75% of the 107,000 people who died of a drug overdose had taken an opioid. Many people taking opioids experience health-related issues, overdoses, and fatal consequences. [2]
These risks can be significantly reduced if people can receive appropriate interventions, such as medications like buprenorphine and methadone. [3]
Prior authorization for these treatments can create several barriers to care, including: [4][5][6]
- Delaying treatment: Prior authorization requires doctors to spend time filling in forms and it can take between 3-14 days for a response from insurers.
- Stigmatizing patients: Various insurers require patients to be closely monitored and tested throughout treatment, which can be invasive and cause individuals to feel stigmatized.
- Interfering with medical decisions: Some requirements, such as limiting medication dosages, can contradict decisions made by medical professionals and may be detrimental to treatment outcomes.
- Poorly evaluating evidence: Often, the person evaluating the authorization request is not a medical professional and is simply assessing if the evidence provided matches the plan requirements. This can lead to a refusal of necessary care.
- Denying treatment: Many treatments are denied during the prior authorization process. This process is partly responsible for the fact that only one-quarter of Americans who require buprenorphine for an OUD receive it.
It is important to note that prior authorization is not the only barrier to care. Without prior authorization, the opioid epidemic would not immediately be resolved, as there would continue to be many individuals who do not seek care for various reasons, and the stigma associated with this condition would persist.
However, by eliminating prior authorization, there would be a significant reduction in these barriers and the associated stigma. Without appropriate treatment being available, many of these individuals will continue to experience severe health risks, overdoses, and fatalities.
Do all insurers require prior authorization?
The requirements for prior authorization can vary depending on the insurance provider and state. Recent regulations have been enacted to limit or prevent insurers from requesting prior authorization for substance use disorder treatments, particularly OUDs. Some states have prohibited these requirements entirely. [7]
Medicare, an entirely government-led insurance company, eliminated the need for prior authorization many years ago. [6]
However, Medicaid, led and funded by several private companies, has a range of requirements for prior authorization that vary by plan and state. Many Republican states are found to have more prior authorization requirements, indicating cost control priorities over patient care. [8]
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