Prior Authorization: When Insurers Practice Medicine

Want to feel better? You’ll need to get permission first. It’s called prior authorization, and it adds another layer of bureaucracy for patients and health care providers to surmount.

Prior authorization was designed as an administrative tool to “limit the prescribing of non-preferred, usually more expensive, drugs by required providers to obtain pre-approval” from insurance companies in order to receive reimbursement.

Though preventing medication from ending up in the wrong hands and supporting appropriate medication use—the supposed intention of prior authorization—was one of merit, this practice instead placed insurance companies as the arbiter of your pharmaceutical and health care needs, not your physician.

The consequences are faced by patients and providers daily.

Providers have reported prior authorizations as one of their greatest administrative burdens, even going so far as to say that the process contributes to burnout and prevents them from delivering high quality care.

The process also hinders physicians from prescribing certain drugs altogether. One survey showed that 66% of physician’s stated that they have chosen not to prescribe a product primarily because of its limited-use status and requirement of prior authorization, even if they felt the patient might benefit from the drug.

One additional study suggests a similar consequence, that physicians may prescribe less appropriate medication to circumvent the time consuming clerical operation of prior authorization.

The alternative treatment plan that could have occurred had prior authorization not existed could be the difference between a healthy life or one of continual medical struggle. Such a failure to receive the best medication for one’s needs in a timely manner not only diminishes the quality of care but also places a strain on the patient-provider relationship—a relationship crucial to the decision-making process.

The continual undermining of physicians as they attempt to do their job of providing quality medical care and treatment to patients is unproductive and negligently causing lasting detrimental effects on both parties involved.

Though distressing, the situation is not all bleak.

Already, 41 states have begun implementing legislation to revise the process of prior authorization and all that it requires of both patients and providers.  One of these states is New York.

In 2017, Attorney General Eric Schneiderman successfully sued Anthem and Empire BlueCross BlueShield “for requiring physicians to complete lengthy prior approval forms for medication-assisted treatment.”

Texas also made progress in minimizing the administrative burden of prior authorization last year by implementing legislation coined the “Gold Card” law. This law exempts physicians from prior authorization requirements if, over a six-month period, they met 90% prior authorization approval rate.

State legislation is a good start, but congressional intervention could expedite the process of its reform. Passing the Standardizing Electronic Prior Authorization for Safe Prescribing Act, which was created to “allow patients to obtain prescription drugs without unnecessary delay,” would protect providers and patients from unnecessary administrative stress and potential medical complications.

Ultimately, patients must continue advocating for themselves in the case of any denial from the insurance companies for medication they need. They must keep communicating with their doctor and appeal all disapproved authorizations. Do not allow insurance companies to dictate the treatment you and your doctor believe is best for you or your loved ones.

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