Physician, patient stories show need to fix prior authorization

Andis Robeznieks
Senior Staff Writer
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Time-consuming. Tedious. Horrendous.

These are a few of the choice words that patients and physicians use to describe the current state of prior authorization (PA), a process which requires physicians to obtain approval from an insurance company or other payer before they can deliver the prescribed treatment or ordered service their patients need.

The stories behind those words are being collected by the AMA as part of its efforts to expose the problems with prior authorization and highlight effective reforms. The AMA's FixPriorAuth.org also features resources such as a PA toolkit. To stay updated on the AMA’s work to fix prior authorization, subscribe to our Advocacy Update newsletter.  

Traditionally, health plans have applied PA to newer, expensive services and medications. However, physicians participating in an AMA-sponsored survey reported an increase in prior- authorization burdens in recent years. This may in part be due to payers placing PA requirements on commonly prescribed drugs and services that are neither new nor costly. 

“When I started here the only procedures requiring prior authorizations were surgeries,” wrote Robin S., who works at a urology practice. “Now medications, radiology and in-office procedures require prior authorization or you do not get paid.”

Robin added that new PA requirements are often buried deep within health plans’ emailed network bulletin.

“They just started requiring us to request prior authorizations on all chemo medications injected or infused through a portal,” Robin added. “We have had patients that have had to put off certain treatments because it takes so long to get a prior authorization back or the hoops we have to jump through are increasingly tedious.”

Lilly H. is a patient who told a similar story.

“My experience with prior authorizations, like that of so many Americans, has been horrendous to say the least—I have literally waited an entire week for simple medications,” Lilly said. “It has negatively impacted my own personal recovery many times over. It has gotten so far out of control that even a simple antibiotic such as amoxicillin now requires prior authorizations—even in its generic form!”

Another doctor reported how PA can interfere with patient-physician relationships.

I have had to make multiple calls and wait as long as two weeks trying to obtain authorization for an MRI when there were abnormal mammogram or pelvic sonogram findings,” wrote Dr. Nina S. “The patients become increasingly anxious about their condition and sometimes, angry at me because they think I’m either withholding care or not concerned about their needs.”

“Enough is enough!”

Dr. Dennis L., a psychiatrist practicing in Hawaii, wrote about having insurance companies put him on “perma-hold” for 10 to 25 minutes.

“Enough is enough,” declared Dr. Irene K., whose private rheumatology practice tracked PA requests over a two-month period. She found a 95 percent approval rate—but some only after four appeals and “countless hours of time and effort.”

The delays it causes prolongs patient pain and suffering and leaves patients vulnerable to permanent joint damage and in some cases organ damage while waiting for this unnecessary administrative barrier to be surmounted,” she wrote.

Dr. Paul P. summed up the PA experience by calling it “time-consuming, frustrating for doctor and patient, and of no clinical benefit.”

One patient whose story illustrates this perfectly is Lyle S., a patient with gastroesophageal reflux disease. He wrote how his chronic cough cleared up after receiving medication samples from his physician. But his new insurance carrier would not cover a prescription for it until he tried three other medications with first taking them once a day for eight weeks and then twice a day for another eight weeks.

“That works out to 48 weeks of trying medications we already knew would not work, before I could hope to get the medication we already knew did work,” Lyle wrote. “By the time the 48 weeks elapsed, the insurance policy ended, and I had to get a policy with a new company, who wants me to jump through the same hoops.”

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Nov 16, 2018
Prior-authorization requirements impose heavy burdens for patients, physicians and health care organizations. Learn about the cost of prior authorization at the Cleveland Clinic.