As a patient, you’re beyond ready to get started on whatever treatment you need to heal or prevent other issues. Sometimes though, you get hit with a prior authorization, which is, without a doubt, healthcare’s most annoying rug pull. Thankfully, we have simple ways to deal with it.

Healthcare is a field where you may consume a given product or service at your leisure but at the same time find yourself stopped by gatekeepers preventing you from getting other routine medical work done. Let’s say you go to the doctor’s office and get an order for an MRI or a prescription medication for acne. Your insurance plan can tell you that you cannot have either of those orders covered until the doctor gives more info as to why you need them. This process grinding your care to halt is called a prior authorization, otherwise known as a PA. Now you might be confused as to why health plans are sticking their nose directly in care decisions your physician makes in your best interest. From the insurer’s perspective, the PA serves to screen for drug abuse, dangerous medication combos, and last but not least, to reduce costs. The logic is straightforward—a health plan doesn’t need to pay for a drug if you can’t get it in the first place. We’ll dive into the incentives a bit later but first you should know more about the process behind the scenes for us to better deal with the problems of PAs.

In most circumstances, if their medication needs a pre-certification, patients are left in the dark. When the pharmacy tries to fill a prescription after your doctor makes the order, that is the precise moment where the insurance plan notifies the pharmacy that a PA is needed, and in turn the doctor’s office gets a fax or electronic message. This is where your medical care gets delayed, because the pharmacist would say that you need to wait for your doctor to deal with the insurance plan first before your drug can get dispensed. At this point you probably won’t know what’s going on unless you’ve dealt with PAs before, so I’m going to pull back the curtain here. A number of medical offices use virtual prescription management services to deal with PAs but there is still a significant amount of manual work required over the phone or fax with the insurance company to prove why you need prescription XYZ or a lab order for ABC. Again, to be clear, this is all happening before patients receive any intended medication or lab work. This is why PAs can take between a day or a month to get approved. The American Medical Association runs a yearly survey of doctors for many topics. PAs are infamous enough to get their own theme. In the AMA’s 2021 review on pre-certifications, 93% of respondents noted that PAs cause at least some delays in care and 82% of respondents noted possible occurrences of abandoned treatment due to PAs. These stats are telling, but I’ll link a screencap of the survey’s original infographic on my Substack post which you’ll find at rushinagalla.substack.com.

At any rate, the ball is still in your doctor’s court to get the PA rolling. They have to send your basic information, every medication for a given condition you’ve tried so far, and usually a rationale for the particular treatment’s medical necessity. On top of that, every insurance company’s PA requirements vary with an uncountable number of possible forms that don’t talk to each other. In theory, each the health plan is supposed to refer to clinical guidance for applying medication efficacy to PA approval. As someone who’s submitted more than a few PAs, I can tell you that it’s like a drawn-out and convoluted job application you write on someone else’s behalf that can still get denied even if you offer the perfect fit. So now your doctor sends a PA to the insurance. Although the next step can seem like a black box, some PAs get run though algorithms that spit out a decision or a real person needs to go over the evidence at hand depending on the specific order. Going with our earlier example, it’s simpler to argue for why a patient needs a specific acne medication versus why a patient needs an MRI or another kind of full body imaging. After taking a while to digest the PA, your health plan gives a yay or nay. If the doctor gets a yay, they will notify the pharmacy or lab and you’re good to go.

If for whatever reason your PA does get rejected, you or your doctor have a right to appeal the outcome or submit a new, updated draft. PA decision makers include both administrators and clinicians working directly for the insurance plan depending on the specific request. In some cases, the insurance plan or provider can suggest an alternative drug that is covered or something else that should be tried first before the PA succeeds for the original intended drug. As you may imagine, neither of those outcomes would be helpful for every patient, especially if there are significant delays in treatment. The insurance company has the inventive to reach the physician’s office directly for PA requests because the information needed to execute the PA is part of a medical record which requires time and effort to access. Another issue with PAs is that you could win a battle and lose the war such that even if a PA gets approved, the insurance still may not cover a whole lot of the cost of a prescription, especially if your coverage has a high deductible. Like them or not, PAs are just a part of the game when it comes to healthcare delivery, but there are ways to handle them.

When your provider is finalizing what treatment and orders you need, that’s a great time to ask if the suggested options require a PA. If you get something other than no for an answer, you are planting the seed for having the office check if there is a high chance of a PA being triggered. Then if a request comes around, everyone will be more prepared to handle the delay. If you’ve dealt with pre-certifications before, you can ask your provider if there is documentation that previously worked for approval. Just bringing up the fact that a PA might be needed causes a little Hawthorne effect: if providers know they’re being watched by the patient, pharmacy, and insurance plan, they will be in tune with the cost-benefit analysis for any given treatment, as well as understanding the ramifications of any issues with the PA process. Now the provider works a little harder on your behalf to save time for all parties involved because you sprinkled in a little preventative action by mentioning the possible need for a PA.

Let’s switch gears to a bigger picture topic but still something that impacts your major healthcare decisions. You’ve probably heard that some doctors or services are labeled as “out-of-network” and have little to no coverage just like you’d find with certain drugs. In the next pod, we’ll demystify and learn how to navigate the times when your insurance benefits won’t help you. Stay tuned and subscribe to Friendly Neighborhood Patient for straight facts about the medical field. I’ll catch you at the next episode.

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