Prior Authorization: What Physicians Wish Patients Knew

February 19, 2024
Monica Ayre

Ensuring continuous and uninterrupted care is a fundamental goal in patient well-being. However, as dedicated physicians striving to enhance the lives of those grappling with health conditions, especially chronic ones, we often face a significant barrier: prior authorization.

According to an AMA survey, 88% of physicians find prior authorization burdensome, and 94% agree it causes care access delays.

Many patients are not fully informed about the lengthy prior authorization process. Even when they are aware, changing regulations can catch them off guard, leading to unexpected delays. These delays are a source of frustration and can interrupt patient care.

Let’s delve into what patients need to be informed about when it comes to prior authorization and understand the critical role they can play in improving this process.

Prior Authorization: What Patients Need to Know

Due to the intricate nature of prior authorization, patients often encounter challenges in obtaining their medications promptly. Understanding the process comprehensively and identifying the key players responsible for these delays is essential.

1. Insurance Company Motives

Prior authorization was introduced with a clear purpose — to cut down on healthcare expenses. In its early phases, it mainly applied to new and costly medications or treatments that insurers aimed to control.

Doctors must follow a complex process involving extensive paperwork, faxing documents, and long phone conversations to obtain permission for these specific medical interventions.

However, over time, this process has undergone significant changes. Nowadays, it extends to a wide range of medications, including generics, and has become a common practice across various health plans. Consequently, physicians and patients now deal with the intricacies of prior authorization for various medical treatments.

2. It Complicates Decision Making

When healthcare professionals and patients work together to devise effective strategies for diagnosis or treatment, the prior authorization process adds an extra layer of complexity. The physician often struggles to predict which treatments are easily accessible for their patients, even when those patients are insured. This unpredictability extends to the pharmacy, where determining which medications are covered and which require prior authorization remains uncertain until the patient arrives.

It’s crucial to understand that despite extensive electronic health records and computer systems, physicians do not have the means to predict which medications a patient can access under their insurance plan. This lack of transparency in prior authorization can be a significant source of frustration, complicating decision-making and impacting outcomes.

3. Uncertainty Surrounding Prior Authorization

Initiating a prior authorization request isn’t a straightforward process. When dealing with medications or procedures that require prior authorization, there’s often a cloud of uncertainty.

Many physicians are caught in a guessing game, uncertain about the precise information health insurers seek. They send explanations and documentation, hoping to align with the insurance plan’s criteria. However, even when the treatment is well-justified and evidence-based, its approval remains uncertain if the submission doesn’t align perfectly with the expectations of the health plan employee.

Adding to the complexity is the fact that those responsible for evaluating prior authorization requests may lack medical expertise. Often, these individuals are not physicians and may not be well-versed in the specific medical condition the patient is facing or the treatment the physician recommends.

This cloud of uncertainty and the involvement of non-medical personnel in the evaluation process leads to a significant diversion of time and resources.

4. A Time-Consuming Process

Prior authorization is indeed time-consuming. Physicians often invest significant time and effort to navigate its complexities to secure essential therapies for their patients.

It’s estimated that physicians in the United States handle nearly 45 prior authorization requests weekly. What’s more, to manage this demanding administrative task, many medical offices have dedicated staff members responsible for the paperwork, and it’s a role that often requires rotation due to its taxing nature.

5. The Impact on Patient Care

The prior authorization process isn’t easy. Physicians often find themselves in a persistent battle, requiring multiple appeals to secure essential medications, tests, or treatments for their patients. While perseverance can eventually lead to success, it underscores the fact that these barriers are unwarranted.

Unfortunately, these delays leave patients in limbo, leading some to become frustrated and discouraged to the point of abandoning necessary treatments. In fact, 80% of physicians have reported that prior authorization has occasionally driven patients to forego essential therapies.

Furthermore, as astonishing as it may seem, up to one-third of patients caught in the prior authorization web never collect their prescribed medications, painting a vivid picture of the profound impact on patient care.

6. Unpredictability in Prior Authorization

The expansion of prior authorization has introduced a new level of unpredictability evident in several key ways.

Health insurance companies frequently adjust the criteria for prior authorization, leading to shifting requirements. The specific documentation needed can vary, and approval decisions may lack consistency. Moreover, even well-established medications may suddenly become subject to prior authorization. These changes underscore the complex and uncertain nature of the process and significantly impact patients and healthcare providers.

The motive behind this unpredictability is often cost efficiency. Insurance companies are pushing for cheaper alternatives, posing challenges for patients and healthcare providers alike.

7. Shifting Coverage

Another challenge in the prior authorization process is the shifting criteria for coverage. For example, a patient with a chronic condition benefiting from a prescribed medication may face unexpected prior authorization requirements during refills if the insurance company no longer considers their condition within the criteria.

Dr. Jack Resneck Jr., MD, former AMA President, draws attention to the issue of patients discovering effective medications for chronic conditions that improve their quality of life but encounter sudden prior authorization demands during refills. Dr. Resneck shares the case of a patient with severe eczema whose life significantly improved with prescribed medication. Despite thorough documentation of the medication’s effectiveness and the patient’s progress, the insurer denied the request, citing that the patient’s condition no longer met their criteria.

8. Physicians’ Frustrations

Physicians share in the frustration experienced by their patients. When doctors initiate the appeal process and meticulously complete all the necessary paperwork upon discovering the need for prior authorization, it becomes a waiting game for the insurance company’s response.

Often, patients may feel like they’ve been waiting for their medication for an extended period, but the reality is that the physician has diligently fulfilled their responsibilities by submitting requests and appeals. The delay primarily lies in waiting for the health plan to respond.

9. Ongoing Efforts

The American Medical Association (AMA) is actively committed to tackling the issues associated with the healthcare prior authorization process. Dr.Resneck emphasizes that the AMA is actively involved in various initiatives in Congress and state legislatures nationwide. Several states have already taken action to address these concerns, and Congress is currently deliberating bills to address the challenges within the Medicare Advantage plans under their jurisdiction. This multi-pronged approach underscores the AMA’s dedication to driving positive change in prior authorization.

How Can Patients Improve the Prior Authorization Process?

While physicians bear the brunt of the time-consuming prior authorization documentation process, the patients ultimately feel the impact.

However, there’s a silver lining—patients can be pivotal in enhancing the prior authorization process. Here’s how patients can make a difference:

  • Engage with Legislators — Collaborate with their elected representatives at federal and state levels. Share their prior authorization experiences to encourage Congress and state legislatures to prioritize solutions.
  • Communicate with Your Physician — If they encounter prior authorization hurdles at the pharmacy, ensure the pharmacy informs their healthcare provider. Physicians can advocate on their behalf and explore alternatives when necessary.
  • Share Your Experiences — Policymakers, legislators, and health insurance executives must understand patients’ difficulties and how they affect their medical treatment. Patient experiences can be a powerful catalyst for change. Patients can share their experiences and frustrations using the AMA platform,

By actively participating in these steps, patients become advocates for the reform of prior authorization, fostering a healthcare environment that prioritizes efficiency and patient well-being.

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