Prior Authorization: Why Is It Holding Up My Medical Care?

You may be in need of a medical procedure, such an MRI, or are due to refill a certain prescription medication. And yet you may find yourself having to wait until your insurer approves coverage for it before you can move forward.

At a minimum, this process, known as prior authorization, can prove inconvenient. Worst case, many physicians say, prior authorizations can in fact put some patients’ health at risk. According to one 2023 survey of more than 600 medical practices, 97 percent of respondents reported that their patients were experiencing delays or denials for medically necessary care due to prior authorization requirements.

What Is a Prior Authorization?

Certain health insurance companies mandate that physicians secure approval from a patient’s health plan for medical procedures (or prescriptions for medications or devices) before the patient can pursue that particular course of treatment. The health care provider must first request approval, and then the patient needs to wait until the insurer issues its approval.

If you have a Medicare Advantage plan, you are likely familiar with these medical prior authorizations. According to one research brief, 99 percent of Medicare Advantage enrollees had to seek out approval for some services in 2021. Today, about 28 million people are Medicare Advantage enrollees, with that number growing steadily in recent years.

What to Do When Your Prior Authorization Is Denied

Your insurance company may deny you prior authorization, even if your doctor has requested a procedure or prescription that they feel you need.

As a result, you may have to pay out of your own pocket for the specific medical service or prescription that you need. Before you do, however, consider filing an appeal. Read more about what’s involved in the appeal process.

How to Speed Up Prior Authorization for Medication

If your health care provider is requesting pre-authorization for your prescription medication, verify that their office has all of your most up-to-date medical history, health insurance, and contact information on hand. The approval process can take a few days, or sometimes more.

If you know ahead of time that you’re going to need prior authorization for a particular prescription, you also may want to call your insurance provider directly.

Note that receiving pre-approval does not always guarantee that your health insurer will completely cover the cost. However, according to the Patient Advocate Foundation, it is “a good indication of your health plan’s intentions to pay for the service or medication.”

Lawmakers Pushing for Reform on Prior Authorizations

Health insurance companies say prior authorizations help patients save money, avoid needless medical treatments, and prevent overprescribing of medications. Yet recent research is highlighting the downsides of prior authorizations according to health care providers and patients alike.

The American Medical Association found that 25 percent of doctors report that delays in pre-authorization led to a patient being hospitalized. In another survey, practicing physicians cited the following problems with prior authorizations:

• Delays in patients’ medical care
• Higher costs for medical practices
• More time spent by medical groups working to meet prior authorization requirements
• Patients missing out on medical treatment altogether when they face denials

At the same time, polls show that many Americans also favor reform around the prior authorization process.

Through several different forms of legislation, a bipartisan group of federal and state lawmakers across the country have been advocating for change on this front.

In 2022, the Seniors’ Timely Access to Care Act secured approval in the House. This bill sought to streamline and modernize the prior authorization process for patients with Medicare Advantage plans. However, it never reached the Senate for a vote.

The Centers for Medicare and Medicaid Services subsequently issued a proposal focused on changes to improve the process. Almost 300 Congress members have rallied behind it. 

Then, in August 2023, State Rep. Mark Green (R-TN) reintroduced legislation focused on reforming prior authorizations. Green, who has his medical degree, is sponsoring the Reducing Medically Unnecessary Delays in Care Act.

“Prior authorization is a roadblock to care – equivalent to a bureaucrat in the waiting room,” said Green in a news release about the bill. “It’s time to put patients first. Pre-authorization doesn’t do that.”