Realism about Prior Authorization
Prior authorization (or prior auth) is a practice used by insurers to make sure that patients requiring expensive treatments, procedures, and drugs are appropriate candidates for those treatments, procedures, and drugs. The reason I am writing this piece today is because I’ve recently read some articles castigating prior auth as just another evil tactic employed by insurers to make life more difficult for sick individuals and it’s not quite that simple.
Prior auth practices can and should be improved but we urge people to realize that the entities that pay for healthcare, primarily employers and the government, want prior auth practices in place. The Affordable Care Act reforms that were implemented years ago had an inflationary effect. That was good in many ways – eliminating pre-existing conditions, requiring comprehensive plans, banning maximums on hospitalization, banning annual and lifetime caps, etc., but the consequence is more pressure to control healthcare costs in other ways, including prior auth.
Let’s focus on expensive drugs. The recent explosion in demand for weight loss drugs is a good example of where prior auth has a role. The advertising and publicity for these drugs is everywhere and sometimes people lose their good sense thinking insurance might cover something which isn’t medically necessary for their situation and which they often wouldn’t choose to pay for themselves. At present, these drugs are appropriate for diabetics and those who are pre-diabetic or obese. There are newer studies too suggesting that some of these drugs might prevent cardiac issues which might expand their availability beyond these categories.
Prior authorization can be particularly challenging when the clinical indications are lacking. Some doctors are unwilling to tell patients that they aren’t appropriate candidates for a drug or procedure so leave that unpleasant task to the prior auth process. Some provider offices aren’t skilled at knowing how to go about gaining approval for procedures that are absolutely necessary which can cause great anguish among patients and families when important procedures are delayed. Other times an insurer requires a less expensive procedure to be completed before a more expensive procedure is approved which can be terribly inconvenient but isn’t always unreasonable. And some physicians are resentful of the process, thinking anything they want done for their patients, should be done. Often this approach is not helpful because it can slow the approval process. We have to be realistic. As long as our system’s incentives are related to volume, prior auth will likely remain a process to contend with.
We can improve prior auth processes. Some states have launched programs which lessen the prior auth burden on physicians who have an excellent track record of the percentage of authorizations granted. That makes perfect sense. Additionally, CMS is requiring payors in the Medicare Advantage, Medicaid, CHIP, and Individual Qualified Health Plans spaces to electronically streamline their prior authorization processes by 2026 and reduce the decision turnaround time for prior auth to a maximum of seven days. But, regardless of reforms, remember that the success of prior auth rests on the quality of the communication between the ordering provider and the patient’s insurance company. There is not too much a patient can do except track the progress of the process and intervene with the provider or insurer if matters aren’t going smoothly.
In summary, prior auth can be a hassle but given the proliferation of expensive treatments, it is not going away. Let’s encourage providers and insurers to make it as sensible as possible so that patients aren’t caught in the middle.
