Insurers sometimes ask doctors and other clinicians to provide more information about intended treatments and medicines for patients before agreeing to pay for these services and products. The goal of this prior authorization is spotting unsafe or inappropriate treatments, which often may not be consistent with evidence or guidelines, according to insurers. But doctors and many patients say the way insurers implement their prior authorization systems have created obstacles that can deny or delay needed care, while putting significant time-consuming administrative burdens on medical practices and consumers.
Health plans often have rules that can protect people from overuse and misuse of treatments and services. Prior authorization has been used for example to try to keep opioid use in check and to prevent prescriptions of medications that can interfere with other types of drugs or potentially worsen existing conditions, according to an FAQ from the trade group America’s Health Insurance Plans (AHIP)
But there also are concerns about how health plans implement prior authorization. Doctors and other medical professionals often face significant hurdles in trying to get needed drugs and treatments for their patients.
Surveys done by American Medical Association (AMA) have found many doctors say delays due to prior authorization have resulted in harm to patients. In some cases, insurers have instituted prior authorization policies for common procedures and approved almost many requests, leading to questions about the need for these restrictions in some cases. A review by a federal watchdog unit found almost one in five — or 18 percent — of prior authorization requests denied by insurer-run Medicare Advantage plans actually fell within coverage and billing rules.