Patients, Need A Helping Hand with Prior Authorization?

Most patients living with chronic disease or illness have experienced the prior authorization process. It is becoming more frequent in healthcare as it is often used to curb costs for insurance companies. As a patient, it often feels as though your health insurance is sometimes working against the common goal of getting you treatment and making you feel better.

Others who work in the healthcare system feel that way too. Everyone dreads calling insurance companies with their long wait times and irritating hold music – the patient, the provider, the support staff, the pharmacist all dislike the prior authorization process. So why hasn’t it been changed?

We will go over more about the prior authorization process to help you navigate the current healthcare system and take the appropriate next steps to assist your healthcare team.

What is prior authorization?

Prior authorization is a common utilization management method used by insurance companies. It challenges whether the right treatment is getting to the right patient. Prior authorization also can bring down the costs of the services and medications for managing disease. It questions if the product or service is appropriate and determines if will be fully or partially covered by the health plan.

Prior authorizations are used for more than just medication. They are also used for services, diagnostic testing, specialists, imaging, etc. Frequently, a patient does not know a provider’s office is getting a prior authorization for a service. It is handled behind the scenes.

For example, if a patient needs an MRI the provider’s office may say to the patient, “We will reach out to them and then the imaging center will reach out to you to make an appointment.”  On the back end, the imaging center is filling out the paperwork to get approval for the treatment from the health plan. Depending on the situation, this is not always an easy process.

Prior authorization from the Provider’s perspective

Prior authorizations are a complex process behind the scenes. There is a lot of back and forth, a lot of phone tag, and long hold times.

The prior authorization process starts with the patient requiring a service or medication. Once the physician is notified by the insurer that a prior authorization is needed, the paperwork and process can be started. Unfortunately, informing the physician is not always a quick process. Many communications are still being done via fax… and when was the last time you regularly used a fax machine?

The physician and their support team fill out paperwork that varies for each insurance company and plan. With almost 900 insurance companies in the United States, it can be difficult to keep track of all the requirements for each company, plan, patient, and service being requested.

Once the paperwork is submitted, that is not the end of the road. Often, insurance companies will request more information and sometimes have their physician speak to your physician for more information on your case. This is called a Peer to Peer, which also comes with various challenges. There have been frequent reports that insurance companies will try to call physician offices at all hours of the night to avoid speaking to a live person, or will intentionally provide the wrong call back number.

Despite all the efforts that go into getting treatment authorized, the claim can still be denied! There are processes to appeal these cases, but it can take weeks to get an insurance company to approve it.

The problem with prior authorization

Physicians and their staff do not get paid for the time spent on the prior authorization process. It is an unwelcomed yet unavoidable administrative process.

Each prior authorization can take hours of time over days and weeks. Multiply that by hundreds of patients and prior authorizations add up. It becomes a lot of work with the mostly altruistic benefit of helping your patients.

So you may be thinking, why can’t other providers or pharmacists do the prior authorization? Because insurance companies request patient information that only your doctor may have access to. Prior authorizations often include lab results, treatment history, and other pertinent information. Adoption of the electronic medical record and increased communication between healthcare providers should only make this process easier and faster.

Insurance companies like the delay of having to go through a physician for submission. Delays save them money. For every delay or roadblock to seek approval, more patients give up on the process.

Important Things for YOU to Know about Prior Authorizations

They are:

  • complicated and are implemented by insurance companies.
  • have unique requirements that may require you to try and fail a treatment before using something that may be more effective.
  • approvals mean the insurance company will contribute to the claim, but that does not mean it will always be affordable.

How You Can Work with Providers

Prior authorizations are an administrative task that require detailed accounts of your disease or illness history. For chronic treatments, you will likely need to seek a re-authorization as often as your insurance company sees fit. This could be annually, every 6 months, maybe every 3 – it’s up to your insurer.

Each time this re-authorization is required, you can remind your provider that re-authorization is coming up so they can prepare and submit before the approval expires. This minimizes the chance of delayed or missing therapy. It is also great to have a copy of the last submission to help your providers gain approval again. Your personal record-keeping can make the process faster.


From the Editor:

If you want to read more about patients and prior authorization try Peggy’s story where she needed authorization over and over again for the same treatment and the same disease.

Or check out Spencer’s story on Patients Rising Stories – his insurance wouldn’t authorize the treatment his doctor said he needed so his suffering was much prolonged.

You can tell YOUR Story on Patients Rising Stories while you’re there. 

If policy is more your taste, find out why the American Academy of Family Physicians decided to fight against prior authorization.


Amanda Demarzo

Amanda DeMarzo, PharmD, MBA, PACS, is the associate director of Patient Access with the National Board of Prior Authorization Specialists, an affiliate of the Accreditation Council for Medical Affairs, based in Oradell, New Jersey. She focuses on how to improve the current health care system as a whole through improved training, widespread certification, and advanced technology for better patient outcomes. Amanda developed a passion for patient-centered care and shared decision making during patient-facing roles over several years.

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