You’re probably familiar with the phrase, “The road to hell is paved with good intentions.”
The same can be said of prior authorizations.
Decades ago, prior authorizations were designed with a reasonable intent: to prevent doctors from ordering expensive and unnecessary tests. The goal was to be cost-effective (nothing wrong with that). These prior authorizations, or pre-certifications, were often implemented in the case of costlier medical exams, like in cancer treatment.
But according to an article in CNN Health, “Today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.”
Prior authorizations frustrate providers and patients alike, as they delay needed patient care and waste medical professionals’ time. Take Paula Chestnut who, when she needed hip replacement surgery last year, an X-ray found irregularities in her chest. Even though a specialist ordered her an MRI for a closer look, her appointment kept getting canceled because her health insurer found the MRI ‘medically unnecessary.’
Months later, after not being able to breathe, Chestnut was rushed to the hospital. Six weeks later, she died because the tumor in her chest was so large—and it was too late.
Unfortunately, Chestnut’s story is not unique. “Waiting for health insurers to authorize care comes with consequences for patients, various studies show,” writes CNN Health. “It has led to delays in cancer care in Pennsylvania, meant sick children in Colorado were more likely to be hospitalized, and blocked low-income patients across the country from getting treatment for opioid addiction.”
Currently, the timeframe for prior authorizations is 14 days, or within 72 hours if it’s an urgent request. Thankfully, this varies state-by-state, so the turnaround time is shorter depending on the location. But in December, the federal government proposed that health plans be required to reduce the wait time to seven days, a change that would take effect starting in 2026.
Many doctors, who find prior authorizations a bureaucratic waste of time, still don’t feel seven days is quick enough for their patients. Some find the process a frustrating way to question a medical professional’s authority. Dr. Julie Kanter, a hematologist in Birmingham, Alabama noted, “I lose hours of time that I really don’t have to argue … with someone who doesn’t even really know what I’m talking about. The people who are making these decisions are rarely in your field of medicine.”
We’ve talked about the numerous downsides to prior authorizations before, but when all is said and done, an insurance company shouldn’t be determining a patient’s care. That’s what doctors are for.
