The mechanism of prior authorization necessitates that an insurance company grants approval for specific treatments before assuming financial responsibility. This includes surgery but also clinical tools such as imaging and medication. This bureaucratic impediment functions mostly as a deterrent, a labyrinthine cacophony of obfuscation. In the words of Sir Topham Hatt, it causes confusion and delay. The deleterious impact on patients is palpable, and the toll on medical professionals is equally corrosive.
Data from the American Medical Association (AMA) in 2023 noted that 94% of physicians reported that prior authorization delays care. Nearly 1 in 4 physicians report that the prior authorization process resulted in serious adverse event to their patient. This bureaucratic quagmire results in real harm to real patients.
Yet, beyond the well-documented patient harm lies an underappreciated consequence: the stress imposed upon our health care staff. No one dedicates their life to health care only to have to attempt the daily Sisyphean task of try to win the coveted prior authorization. The same AMA study noted that physicians and their staff spend 12 hours each week completing prior authorizations. On average, a practice completes 43 prior authorizations for each physician per week.
To be blunt, there are legitimate economic apparatus in the insurance market that warrant a prior authorization structure but the process has become corrupt. It’s a tangible manifestation of a system designed to interpose a wedge between physician and patient in a manner which is borderline insidious. I’ve written about prior authorization for about a decade; here, here, here, and here to name a few.
Rather than regurgitate the same arguments, I thought I would take the opportunity to ask our staff about their journey through the Byzantine web weaved by the forces of prior authorization.
They were more than happy to oblige. So what precisely did they have to say?
Haley N. Kirby, MSEd., ATC/L
Director of Operations for Neurosurgery
“Prior authorization has become an increasing threat to our ability to run an efficient practice. We can’t keep up. It’s pervasive, and it’s impacting my staff and our ability to treat patients. The other challenge we feel is that it’s hard to win the game if the rules keep changing in the opposition’s favor. We have difficulty planning an actual reliable OR schedule.”
Samantha Schmitt
Neurosurgery Practice Manager
“For 7 doctors, we utilize 3 full-time staff just to do prior authorizations for hospital procedures. Each authorization can take anywhere from 15 minutes to 3 hours. If not more, waiting on a response and getting to the correct area of authorization.”
Victoria Hyatt, PA-C
Spine Clinic Physician Assistant
“Prior authorization stops us from being able to take care of patients, and it’s very stressful. They always wait to the last minute, and it creates so much a tension. I feel it’s an intentional tactic so that we are forced to cancel the case. And when we can’t get approval, the patients are looking to us for answers.”
Chelsea Lukenbill, PA
Spine Physician Assistant
“It’s difficult to even set up the call to speak with a provider. It’s not uncommon to be transferred multiple times before you speak with the person who schedules the appointments. Then you have to schedule a time for them to call you, which may not be until days later. When you do finally have the scheduled phone call, the provider may not even be in the same specialty.”
Stephanie James
Neurosurgery Patient Navigator and Coordinator
“I see where cases get delayed and some patients surgery dates have to be pushed out further because of the prior authorization, and all I can say is that Prior authorization really stinks and it’s the patients who are ones paying the price. Some of the patients really need the surgeries but the authorizations are what stop them.”
Erin Roberts, RN
Spine Nurse Emeritus
Erin has probably had the most interaction in our prior authorization practice, and wrote about it here.
“My favorite subject… When I deal with denials and call insurance companies, I’m transferred a minimum of three times, and everyone tells me completely contradicting information- and then when I call again the next day to check the status of things- I am again told conflicting information. This is difficult in urgent patients who need surgery within 2-3 weeks. Turnaround time for case determinations varies widely with insurance companies and we are often at their whim of determining when patients can have approval for surgery.”
Personally, I think the quote from my patient in clinic sums it up the best.
Patient CK
Spine Patient
“What the insurance company did to me in delaying my surgery was criminal. I was suffering for months. It was horrible, absolutely horrible.”
Our patients and our clinical teams deserve better. Tell Congress to fix prior authorization. The Improving Seniors’ Timely Access to Care Act has been reintroduced in the House and Senate (S. 1816/H.R. 3514). Its goal is to streamline prior authorization for Medicare Advantage.
It’s a start in the right direction. I know Haley, Sam, Tori, Stephanie, Ashley, and Erin would really appreciate it.
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.
Richard P. Menger, MD, MPA, FAANS
USA Spine Institute
Mobile, Ala.
