Exposing the True Dangers of Prior Authorization

In the intricate realm of health care management, few processes provoke as much frustration and controversy as prior authorization (PA).

It’s a system that the American Medical Association (AMA) refers to as “costly, inefficient and responsible for patient care delays,” referring to the complexities of prior authorization as “a nightmare.”

Let’s delve into the multifaceted issues, including the dangers of prior authorization, shedding light on its detrimental impacts on patients, medical providers, and the health care system as a whole.

What is Prior Authorization?

Also known as pre-authorization or pre-certification, it is a process used by insurance companies, health plans, or pharmacy benefit managers to determine if they will cover the cost of a prescribed medication, medical procedure, or treatment before it is provided to the patient.

It requires medical providers to obtain approval from the patient’s insurance company or payer before proceeding with certain health care services.

Dangers of Prior Authorization

Prior authorization can be a complex and time-consuming process for medical professionals, requiring them to navigate through administrative requirements, submit documentation, and engage in

Studies show that for most physicians (74%), prior authorization takes between 2 to 14 days, but for 15%, it can take from 15 to more than 31 days. 32% of these doctors state that patients often abandon treatment while waiting for prior authorization, and 50% report that patients sometimes abandon treatment.

Some of the most common dangers of prior authorization include:

Delayed Care and Increased Stress

For patients, the hurdles presented by prior authorization can be both daunting and distressing.

When a recommended treatment or medication is subject to prior authorization, it often translates into delays in receiving essential care. These delays can exacerbate health conditions, prolong suffering, and diminish overall quality of life.

Also, the uncertainty surrounding whether authorization will be granted adds a layer of anxiety and stress, compounding the already challenging experience of navigating the health care system.

Administrative Burdens and Impeded Workflow

This administrative burden not only detracts from patient care but also contributes to provider burnout and dissatisfaction.

The arbitrary denials and endless appeals processes associated with prior authorization also impede the workflow of medical professionals, hindering their ability to deliver timely and effective treatments.

Escalating Costs and Diminished Revenues

From a financial standpoint, the repercussions of prior authorization reverberate throughout the health care ecosystem.

While insurers justify PA as a means to control costs, the reality often paints a different picture.

The resources expended by medical providers to navigate the prior authorization maze translate into increased overhead costs, which are ultimately passed on to patients and payers. The administrative overhead associated with prior authorization detracts from the efficiency of health care delivery, further inflating expenditures.

Studies show that the average cost of prior authorization approval for primary care practices ranges from $2,161 to $3,430 annually per full-time physician.

For health care providers, the delays and denials inherent in the prior authorization process can result in lost revenue opportunities, as treatments are deferred or patients seek alternative providers who can offer expedited care.

Compromised Outcomes and Patient Safety

Beyond the realm of administrative inconvenience and financial strain, the true dangers of prior authorization manifest in its potential to compromise clinical outcomes and patient safety.

When patients are forced to endure delays in receiving medically necessary treatments due to prior authorization requirements, the consequences can be dire. Conditions may worsen, complications may arise, and in some cases, irreversible harm may occur.

According to Heather McComas, PharmD, director of the AMA’s administrative simplification initiatives, 80% of physicians report that prior authorization can lead to patients completely abandoning a prescribed or ordered course of care, with one-third of physicians reporting that it has led to a serious adverse event for a patient in their care, including hospitalization, permanent impairment or even death.

Creating a More Equitable Health Care Landscape

From patients grappling with delayed care to providers navigating bureaucratic hurdles, the ramifications of prior authorization reverberate far and wide. By encouraging dialogue, advocating for reforms, and championing patient-centered approaches, we can strive toward a health care system that prioritizes accessibility, affordability, and quality of care for all.

Policymakers, insurers, medical professionals, and patient advocates must collaborate in forging a path forward. One that ensures the integrity and sustainability of our health care infrastructure while still safeguarding the well-being of patients

If you feel that your health has been negatively affected due to the burden of prior authorization, a qualified health insurance attorney can be of assistance to you. The Law Office of Matthew L. Sharp often assists individuals in similar situations to yours seek justice when insurers have employed bad faith tactics in dealing with them.