From my extensive experience in the medical field, the mention of prior authorization evokes a range of emotions—from dread to empathy to relief. It's a process that most doctors would prefer to avoid, akin to navigating a storm in murky waters. The methods for obtaining them are varied, from the electronic platforms to the insurance company's website and the dreaded telephone call. This is not a task for the inexperienced but for the seasoned professional who has served as a patient and company advocate against the insurance company and as a bridge between the patient and doctor.
Obtaining prior authorization is more than just filling out a form and submitting it to the insurance company. It's a process that requires technical knowledge, good listening, and critical thinking skills. The technician or manager must listen to the doctor’s explanation of the diagnosis and the reasons for prescribing certain medications. They must then become knowledgeable through listening, and research to understand how insurance works and, most importantly, when they will pay for medication. Let us walk through the process.
How Does Prior Authorization Work?
From the patient's perspective, the prescription process resembles a journey. It begins when the health care provider writes the prescription and sends it electronically to the pharmacy. Eager and often unaware of the behind-the-scenes procedures, the patient drives to the pharmacy, expecting a quick turnaround. However, it typically takes about 2 hours for the prescription to be processed through the pharmacy’s clearinghouse. This situation highlights the importance of clear communication, as any delays can lead to frustrated patients who may believe their medication was never sent.
My company's current EMR system will display sent, or pharmacy received and verified when prescriptions are sent. Nevertheless, some pharmacies will inform the patient that their medication was never sent, or the insurance does not cover the medication. The patient's pupils dilate, and hyperventilation sets in (or, maybe, that is just me). After the anger or shock dissipates, the phone calls start, and the endless requests for prior authorizations from the pharmacy. If the pharmacy does not get a response the same day, they will send a request daily.
Oftentimes, the pharmacy will start the prior authorization via fax, phone call or electronic prior authorization request. Other times, it is a call to the pharmacy if there is no updated insurance card copy in the chart, involving requesting bin, PCN, group, and ID information needed for electronic prior authorization submission. Next, will it be simply completing a form and getting denial or approval, or will you have to do a deep dive into several chart notes to see if they have tried other medications or will everything you need be in that one note? Hence, documentation is essential. Obtaining prior authorization should not be difficult if past treatments, reactions, or allergies are listed. No one should spend several minutes searching for information. But that is not always the case.
The Patient Was Denied, Now What?
During the late 90s and early 2000s, it was not difficult to obtain an approval. If you tried at least one other medication, you were almost guaranteed to get the doctor-recommended medication. Today, some insurance companies require that patients try at least 2 to 4 different generics, have a life-threatening allergy, or explain to them (short thesis paper) why they should try the brand vs a generic. If there is a denial and the prescribing doctor is adamant that the patient should have the medication, an appeals process is started. This involves submitting it electronically or by mail or having the doctor call. The latter is often when the doctor relinquishes power and changes the medication. However, electronic submission or mail is left to the tech. Also, the appeals process can take up to 30 days unless you mark it urgently, and you will get a response in 3-5 business days. The patient may remain untreated while waiting for a decision, jeopardizing their eye health.
The average time to complete a simple prior authorization is about
3-5 minutes, but it can sometimes stretch to 10-15 minutes. For those working in a small office with a patient load of 30-40 daily, the doctor may opt to change the medication rather than invest staff time and energy in obtaining an authorization. However, multi-specialty practices juggle patient needs, pharmaceutical reps' demands, and insurance companies' authority, making the process more complex.
Are Prior Authorizations Truly Necessary?
The answer is yes. They ensure patients receive affordable treatment and prevent doctors from being influenced by pharmaceutical companies to make unnecessary medication changes. However, when a single entity is tasked with advocating for a patient's right to the appropriate medication, it raises the question: What's the point of insurance if it does not guarantee access to the necessary medication? We pay significant premiums each year, only to be met with denials.
According to a report in The Hill, a groundbreaking bipartisan bill has been introduced by Representative Mark Green of Tennessee, driven by his own harrowing experiences with treatment delays after being diagnosed with colorectal and thyroid cancer. This collaboration between both sides of the political aisle is a beacon of hope, signaling a united effort to tackle a pressing issue that affects countless Americans.
The bill, known as the Reducing Medically Unnecessary Delays in Care Act of 2025, aims to revolutionize the prior authorization process for Medicare, Medicare Advantage, and Part D prescription drug plans. By empowering specialty-certified board physicians to make critical treatment decisions, the legislation seeks to eliminate unnecessary obstacles that hinder patient care.1
The report highlights a startling statistic: 94% of doctors believe that prior authorizations have adversely impacted their patients, with 23% of these cases resulting in hospitalizations. This raises a pivotal question: who should truly dictate the course of patient treatments?
It is clear that the prior authorization process is in dire need of transformation. As lawmakers encounter the health care system from the patient's perspective, they grasp the urgency of timely care and the potential tragedies that delays can inflict. This issue transcends age; it affects every segment of society, from the single mother striving to secure a prescription for her child to the young professional seeking specialist guidance, and the elderly couple in need of procedures to enhance their quality of life. We must recognize that this is not just a health care issue—it's a matter of fundamental human dignity that impacts us all.
So, when you see your prior authorization tech or manager sitting at their desk staring out a window or at their computer shaking their head, know their frustration is not with the patient, the doctor, or the pharmacy. It's with a system designed to put profit over people. There is a saying that goes, "The struggle is real." Should it be? OP
Reference
- Fields A. Bipartisan bill seeks to reform prior authorization. The Hill. March 27, 2025.
