Prior authorization: Why insurers require approval for some drugs, tests and procedures.<\/p>\n
It can be frustrating to arrive at the pharmacy to pick up a new prescription only to learn your insurance company requires prior authorization.\n<\/p>\n
Prior authorization is a requirement that a doctor, hospital or other healthcare provider obtain approval from a health insurance company before a specific drug, procedure or medical test will be covered.<\/p>\n
\u201cHealth insurance plans are increasingly using prior authorization to determine what medical care we get,\u201d said Kevin Brasler, executive editor of Washington Consumers\u2019 Checkbook<\/a>. \u201cCertain drugs or classes of drugs, any elective surgery or medical imaging tests must be approved by the health insurance plan before you can go get that.\u201d<\/p>\n The process can leave patients waiting for days to learn whether their insurance will cover a treatment, medication or diagnostic test.<\/p>\n Insurance companies said prior authorization ensures treatments are medically necessary, encourages the use of lower-cost alternatives when appropriate and helps prevent unnecessary spending and fraud.<\/p>\n According to AHIP<\/a>, the national trade association representing the health insurance industry, \u201cPrior authorization is an important safeguard used by both public and private payers to ensure patient care follows clinical guidelines. It helps reduce patients\u2019 exposure to low-value, unsafe or inappropriate care.\u201d<\/p>\n \u201cOne thing they do, for example, is say, \u2018The doctor\u2019s prescribed this expensive drug, we want you to try the less expensive drug first, before you can use the more expensive one,’\u201d Brasler said.<\/p>\n He said patients are not required to simply accept an insurance company\u2019s decision. According to an American Medical Association survey<\/a>, doctors now juggle an average of 43 prior authorization requests per week.<\/p>\n \u201cThat\u2019s what\u2019s frustrating now, not just for patients, but for doctors,\u201d Brasler said. \u201cSurveys of doctors found they\u2019re spending 15-plus hours a week, on average, just fighting these prior authorization battles for their patients.\u201d<\/p>\n Most people do not appeal prior authorization denials. Fewer than 1 in 10 denied requests are appealed, according to a Kaiser Family Foundation analysis<\/a> of data that Medicare Advantage insurers submitted to the Centers for Medicare & Medicaid Services between 2019 and 2022.<\/p>\n
\u201cThe first step, if you\u2019re denied under prior authorization is to ask the doctor to go to bat for you,\u201d Brasler said.<\/p>\n