Medical prior authorization “‘wreaks havoc on patient care,’ according to a recent release from the American Medical Association (AMA),” reports Health Policy Today*. The organization’s 2023 survey “found prior authorization was responsible for care delays in nearly every instance and treatment abandonment for nearly four out of every five patients.”
Medical insurance prior authorizations are a process where healthcare providers must obtain approval from a patient’s insurance company before proceeding with a specific medical treatment, procedure, or medication. The supposed purpose of prior authorizations is to ensure that the prescribed treatment is medically necessary and covered under the patient’s insurance plan.
Many people view prior authorizations as problematic because they can delay necessary treatments, add administrative burdens, and sometimes result in denied coverage for essential care. Critics argue that this process often prioritizes cost control over patient care, making it feel like a barrier rather than a safeguard.
The insurance company then reviews the request against their coverage policies and medical guidelines. Based on this review, the insurance company either approves the request, allowing the treatment to proceed, or denies it, often providing reasons and sometimes suggesting alternatives, but this often causes problematic delays. For some patients, “even two weeks’ wait for authorization means continued disease progression, and potentially fewer treatment options than if care could have been initiated immediately.” If the authorization is not obtained, the patient may bear the full cost if the insurance denies coverage.
Twenty-five percent of the survey respondents “indicated that prior authorization ‘has led to a serious adverse event for a patient in their care.’” These outcomes include “hospitalization and life-threatening events up to permanent disability, even death.”
Patients and providers can appeal denials by providing additional information to support the need for the treatment, but, for the healthcare provider, prior-authorizations are “a torturous process…cited as a top contributor to burnout.” They expend valuable time, energy, and focus in an effort to “justify their expert medical opinion to someone who is only looking after the bottom line.”
Insurance denials are almost deadly for me. When I experience a treatment gap it’s like I’m going back to hell. My functionality declines dramatically, pain levels rise, other symptoms increase, and everything falls apart again.
Fortunately, my understanding of the field of Interpersonal Neurobiology gave me an advantage. I was able to write a five-page notated, footnoted, expert-quoting, personal biomarker data-bearing paper that seems to have convinced my insurance company that I know what I’m talking about, know what I need, and need what I need when I need it. Since then, they have not denied a claim for my PTSD treatment, thank goodness!
While the intent behind prior authorizations is to ensure appropriate use of medical services and manage healthcare costs, the execution often leaves patients and frustrated and harmed and practitioners burned out.
*“Survey Shows Prior Authorizations ‘Wreak Havoc on Patient Care,’” Health Policy Today, July 22, 2024
