Op-Ed: Is prior authorization protecting patients or insurers?

Sticking with these prior authorization processes prevents physicians from providing critical services and delays patients from receiving timely care
Marlene Sneha Puthiyath

It’s a situation I am sure some of you have encountered: You visit your physician and are told you need a specific medication, treatment or procedure. But then you are told that said medication, treatment or procedure requires prior approval from your insurance company. Sometimes, the wait is tolerable. Other times, the approval process seems to take forever.

Prior authorization — sometimes referred to as prior approval or precertification — requires physicians or health care providers to obtain advanced approval from an insurance company to determine if the patient qualifies for payment coverage for a service.

In certain situations, the prior authorization process can be quite lengthy, resulting in delays in treatment or care. According to a 2020 survey released by the American Medical Association, 94% of physicians report care delays due to an insurance company’s prior authorization requirements. 

When it comes to emergencies, physicians will always provide critical, life-saving care first — regardless of prior authorization requirements and the insurance carrier’s policies and procedures. However, when it comes to non-emergent situations, things become a little dicey. 

Non-emergent health conditions encompass a wide range of diagnoses, from lower acute back pain and shoulder injuries to more serious conditions like diabetes, which require immediate attention and care. In these non-emergent situations, prior authorization doesn’t just delay care — it can prevent it altogether. The delays caused by prior authorization increasingly frustrate patients to the point at which they end up abandoning the majority of treatment plans altogether. When these complications in the authorization process and subsequent delays occur, it often leads to significant worsening of a patient’s health, to the point at which patients may require immediate medical attention and/or hospitalization.

Unforeseen consequences

Health insurance companies argue that prior authorization is necessary to contain health care costs. However, denying or delaying a patient from receiving an essential prescription, test or treatment can have costly consequences, particularly when those delays lead to hospitalizations. The admission to the hospital alone may wipe out any initial cost savings.

Another costly part of prior authorization is so-called step therapy, aka “fail first.” This policy requires patients to go against their doctor’s recommendations and try and fail on one or more medications before their insurer will cover the cost of the initially prescribed treatment. Medications can take weeks, even months, to demonstrate whether they are effective, which considerably delays proper treatment. Step therapy, which was initially intended to be cost-effective, is, in fact, more expensive in the long run.

Insurer barriers to doctor-recommended therapies don’t just take time away from the patient. They also take time away from physicians providing care. Physicians complete about 40 prior authorizations per week on average, and the paperwork for them can take up to 16 hours. The time spent by physicians and health care providers carefully filling out forms to ensure that insurance companies will approve treatment is a substantial loss in patient care.

Recognizing the problems of prior authorization, the Medical Society of New Jersey conducted a study in collaboration with New Jersey’s Department of Banking and Insurance. It analyzes these issues by examining approval and denial rates; how long prior authorization processes take; and services and medications subject to these requirements.

Through the study, the MSNJ found that prior authorization requests for general care could take up to 15 days and urgent care up to three days. In the world of health care, where timing is imperative, those three to 15 days are significant interruptions in a patient’s treatment and can result in potentially fatal consequences. In one devastating example, a 25-year-old patient in Baltimore diagnosed with advanced skin cancer had skin scans delayed by prior authorization requests. By the time the doctor was able to recommend treatment, the patient had passed away.

Critical care delayed

In New Jersey, the MSNJ study found that critical and lifesaving care was delayed in the vast majority of instances. One example included a primary care physician in central Jersey who described what happened when a patient came into their office with mild exacerbation of asthma and a history of hospitalization for the condition, only to have their steroid inhaler denied. Certain conditions may not be urgent at first but can quickly develop into an emergency situation, further driving up costs within the health care system. While the physician and their staff exchanged communication with the insurer over the course of two days to get the prior authorization for the inhaler approved, the patient ended up hospitalized for four days, a situation that may have been avoided completely if the inhaler was not denied in the first place. 

Insurance companies certainly don’t make the prior authorization process an easy one, as the foregoing example illustrates. In their study, MSNJ had a lot of difficulty reporting on the complete volume of services and drugs that require prior authorizations because payers make it challenging to understand ever-changing policies. Similarly, insurers also keep information under lock and key with private portals. This lack of transparency can create roadblocks for physicians when payers deny prior authorizations for unknown reasons.

Despite the demanding and extensive prior authorization process, MSNJ’s study found that the majority of requests were approved. This raises a few questions. Why make physicians jump through hoops if approval is guaranteed in over 90% of situations? More importantly, how can the health care industry improve this flawed, time-consuming process?

The MSNJ study concluded that there are serious reforms needed to the prior authorization process, including further automation and transparency. For example, creating an electronic prior authorization system would greatly lessen the time and effort required to comply with payer prior authorization policies. Based on approval rates alone, insurance companies should also reduce the number of services and medications requiring prior authorization. The net effect would not only benefit patients, who would receive prescriptions and services on time, but also providers, who could provide more patient care after regaining previously lost time spent laboring over prior authorization requests.

Lawmakers must focus on eliminating prior authorization requirements or, at the very least, ensure that the process is standardized, transparent and immediate. Reforming, streamlining and in some cases eliminating prior authorization mandates will ultimately benefit both the patient and the physician. Procrastinating reform of the prior authorization processes only prevents capable physicians from providing critical health care services and delays patients from receiving care in their time of need.

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