Prior Authorization Process: Persistent Challenges and Calls for Transparency

The prior authorization process, which mandates pre-approval from health insurers for medical treatments and prescription medication renewals, continues to present significant challenges for patients in the United States. Insurers argue these authorizations are essential for ensuring safe, evidence-based care and for managing healthcare costs, especially for expensive treatments.

However, medical organizations like the American Medical Association describe the process as opaque and overly complex, leading to care delays and increased administrative burden.

Patients frequently report prior authorization as a major barrier to accessing necessary care. Despite recent pledges from the insurance industry to simplify the process, patient experiences indicate persistent issues, and medical advocacy groups express skepticism regarding the effectiveness of voluntary changes.

Impact on Patients

Numerous individuals have reported experiencing significant delays and denials for doctor-recommended treatments due to the prior authorization process:

• Jaclyn Mayo, a patient with multiple sclerosis, experienced a two-week interruption in her prescription medication, Zepbound. Her prior authorization expired without explicit notification, resulting in a return of some of her symptoms.
• Sheldon Ekirch of Henrico, Virginia, faced two years of persistent denials from Anthem for intravenous immunoglobulin (IVIG) treatments for small-fiber neuropathy. Her parents spent approximately $90,000 from retirement savings to cover the treatments, which cost about $10,000 per infusion. An external review by the Virginia Bureau of Insurance eventually overturned Anthem's denial. An Anthem spokesperson stated the treatment did not align with the company's evidence-based standards but affirmed respect for the external reviewer's decision. Ekirch anticipates renewed authorization challenges when her COBRA coverage with Anthem concludes in March.
• Payton Herres, 25, a heart transplant recipient, initially faced denied coverage from Anthem for a lifelong anti-rejection medication. An Anthem spokesperson later confirmed the medication's approval, attributing the initial denial to a lack of consideration for Herres' treatment history. Herres will require new authorization in September.
• Anna Hocum, 25, also experienced repeated denials for treatment of a rare genetic lung condition. Her parents covered initial costs with assistance from a crowdfunding campaign before the insurer reversed the denial. This approval is valid for 12 months.

A KFF poll indicated that 39% of patients with chronic conditions considered prior authorization the most significant burden in receiving care.

Industry Commitments and Reforms

In June, insurance industry leaders pledged to simplify prior authorization by reducing the scope of claims requiring approval, accelerating turnaround times, and providing clearer explanations for decisions. An industry press release in January reiterated this commitment to reform efforts.

However, when contacted, half of more than a dozen major insurers who signed this pledge did not provide specific details on which healthcare services no longer require prior authorization. AHIP, the health insurer trade group, and the Blue Cross Blue Shield Association also did not offer specifics on changes to prior authorization requirements. The Department of Health and Human Services has provided limited updates, focusing on electronic submission for requests.

Some insurers have cited specific reforms:

• Aetna CVS Health began bundling prior authorizations for musculoskeletal procedures and for lung, breast, and prostate cancer patients.
• Humana removed prior authorization requirements for diagnostic services related to colonoscopies.
• UnitedHealthcare eliminated prior authorization for certain nuclear imaging, obstetrical ultrasound, and echocardiogram procedures as of January 1.

Bobby Mukkamala, president of the American Medical Association, expressed skepticism regarding the follow-through on voluntary changes, noting that insurers have made similar pledges previously without delivering meaningful change. He emphasized the need for transparency to evaluate real reforms. Matt Toresco, CEO of Archo Advocacy, suggested that insurers' primary fiduciary responsibility is to financial markets rather than to patients.

Navigating the Prior Authorization Process

Patients and providers can employ several strategies to manage prior authorization requirements:

• Understand Expiration Dates: Prior authorization policies vary by insurance company and plan. Patients can contact their insurer or pharmacy benefit manager to determine authorization duration and expiration.
• Submit Requests Promptly: The approval process can be lengthy. Initiating renewal requests well in advance of medication running out may help prevent treatment interruptions.
• Request Expedited Reviews: If a delay in medication could significantly impact health, patients can ask their doctors to request an expedited review from the insurer. Federal regulations mandate decisions within 72 hours for urgent requests for employer-based, Medicare Advantage, Medicaid, and Children's Health Insurance Program plans, though this specific rule does not apply to medications.
• Explore Alternative Treatments: Physicians may be able to prescribe alternative medications that are more readily approved by a patient's health plan, as formularies (lists of covered drugs) can differ and change.
• File an Appeal: If a prior authorization request is denied, patients have the right to appeal the decision. Research indicates that approximately half of appeals for prior authorizations or claims denials are successful. Including detailed medical records, such as documentation of failed alternative treatments, can strengthen an appeal.