PA Roadblocks, ADHD Life Expectancy, & Barriers To HIV Prevention/Treatment

Hey all,

Reading the Modern Healthcare piece on prior authorization, I couldn’t help but reflect on how payers approach it so differently depending on who owns the care provider. It’s amusing how prior authorization decisions seem to shift from “not essential” to “automatically approved” when the insurer owns the provider. Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX)

(Modern Healthcare) and Insurers’ Increasing Claim Roadblocks

Providers report growing frustration as insurers implement stricter policies, such as expanded prior authorizations and administrative burdens like Blue Cross Blue Shield of Michigan’s fees for rejected claim appeals and UnitedHealthcare’s added Z-code requirements for molecular tests. While insurers argue these measures improve efficiency and cost control, providers contend they increase administrative workloads and delay care, sparking public backlash and policy reversals, as seen with Anthem’s anesthesia reimbursement cap. With mandated transparency on claims denials starting in 2027, the debate underscores mounting tensions between insurers, providers, and patients. Full Article.

(New York Times) ADHD’s Impact on Life Expectancy

New research shows individuals with ADHD may face a reduced life expectancy due to higher risks of accidents, substance abuse, and mental health challenges. Experts stress the importance of early diagnosis and targeted interventions, such as therapy and lifestyle management, to address these risks. Such efforts could significantly improve both long-term health outcomes and quality of life for people with ADHD. Full Article.

(Healthcare Uncovered) Barriers to HIV Prevention and Treatment

Despite PrEP reducing HIV risk by 99%, insurers are making access difficult through preauthorization, high copays, and restrictive coverage, while categorizing life-saving HIV medications as costly “specialty drugs.” The Supreme Court’s review of the ACA preventive services mandate could worsen access by allowing insurers to exclude crucial preventive treatments under religious or other objections. Policymakers have introduced legislation like the PrEP Access and Coverage Act to ensure affordability, but with the ACA’s future uncertain, HIV prevention and treatment face mounting challenges. Full Article.