Prior authorization (noun): the process by which an insurance company evaluates a recommended health care service including a prescription, test, or treatment, is medically necessary and covered by the insurance plan.
Initially prior authorization was valiantly born to try and reduce unnecessary testing and control health care spending. With concerns that physicians were ordering unnecessary tests, prescribing unindicated medications, or moving forward with unproven treatments, prior authorization was implemented. This process, purportedly using guidelines to determine appropriateness of care, requires pre-approval for prescribed testing and treatments. The irony is that it has likely curtailed appropriate testing and treatment, while simultaneously delaying appropriate care for our patients and contributing to increased health care costs in overhead spending. A survey by the American Medical Association found that 69% of physicians reported that prior authorization resulted in ineffective initial treatments, 68% reported prior authorization resulting in additional office visits, 42% stated this resulted in immediate care or emergency department visits, and 29% reported this process resulted in a hospitalization. The Council for Affordable Quality Healthcare reported an increase in $1.3 billion on administrative costs in one year specifically related to prior authorizations.
In the end, this costs our patients. It costs them access to necessary medications, indicated testing to help guide treatment, and delays or cancels necessary procedures and surgeries. Patients are denied covered care, leading them to either continue in suffering or pay out of pocket for health care which should be covered by their insurance plans. Equally bad, the bureaucracy of prior authorizations can lead to delays in diagnosis or delays in care — placing patients at risk for worsening disease processes and the need for more significant interventions.
Where did this go so wrong? How is this affecting our patients? And most importantly, what can we do about it?
In this upcoming series on the Neurosurgery Blog, we highlight the current state of prior authorization and the impact it has had on our ability to provide appropriate care to our patients. We also highlight what we, as a specialty and profession, are doing to improve this process for neurosurgeons, physicians, and, most importantly, our patients.
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on X by following @Neurosurgery and using the hashtags #FixPriorAuth and #PriorAuth.
Krystal L. Tomei, MD, MPH, FAANS, FACS, FAAP
Rainbow Babies and Children’s Hospital
Cleveland, Ohio
