healthcare accountability

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    The Prior Authorization Desk Needs Prior Authorization

    ByHugh Jass

    I have reviewed the federal audit, and the document coughed before I did: Health Share of Oregon’s prior-authorization denial process was not consistently meeting the rules that make those denials lawful, timely, understandable, and properly reviewed. The HHS Office of Inspector General examined 100 Medicaid denials and found that 21 failed to comply with at least one federal or state requirement. This is the bureaucratic equivalent of a courthouse discovering its front door requires a permit.

    The failures were not confined to one ceremonial checkbox. OIG identified problems involving the expertise used to make decisions, the content of denial notices, the timing of those notices, language access, and communication with providers. In other words, the system responsible for explaining why care was denied sometimes struggled with the basic administrative duties required to explain a denial. Exhibit A had a pulse, and it was asking where Exhibit B went.

    OIG estimated that the findings could represent 5,677 noncompliant denials during calendar year 2023. That estimate does not mean every denial was improper, and the audit does not decide whether particular treatments were medically necessary. It identifies something more elemental and, in its own way, more haunting: the gatekeeper enforcing authorization rules did not consistently satisfy the rules governing its own decisions.

    The agency issued four recommendations to Health Share of Oregon. Those recommendations are the usual institutional medicine: review procedures, improve oversight, train the machinery, and make sure the paperwork behaves before it is allowed near another human life. Necessary, presumably. But somewhere in the records room, a form is being prepared for the denial department itself.

    Therefore, as a matter of administrative justice, the prior-authorization desk should submit its own application for prior authorization. It should demonstrate expertise, deliver a timely and understandable notice, provide language access, and consult the people who actually know what is happening. Until then, patients and providers are being asked to trust a stack of paperwork that the stack could not consistently complete correctly. The filing blinked first.

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    The Miracle Arrives With a $3.2 Million Invoice

    ByPhil McCracken

    Here is the money trail presented by the scenario: children’s-hospital and academic micro-dystrophin research tied to Nationwide Children’s Hospital moves into Sarepta’s private commercialization pipeline, and the number waiting at the end is $3.2 million. Nationwide is presented as receiving licensing and royalty revenue; families and payers are presented as facing the cost. That is a remarkable invoice-routing system: the science gets described as a shared triumph, while the people who need it are treated like they wandered into the pricing meeting without a badge.

    Profit is not the villain. Pretending the public-private pipeline ends at “innovation” is. If the figure and licensing arrangement are accurate as presented, the contradiction is hard to miss: the breakthrough gets inspirational music, the commercial deal gets revenue, and the family gets a financial document written in the ancient language of “please indicate which organ you’d like to sell first.” Nobody has to oppose useful medicine or licensing to ask why the people carrying the medical and financial risk get no meaningful seat at the pricing table.

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