Prior authorization

 As I’m sure you know, before you can get treatment or medication your doc may have to convince your insurance provider that you need it. Prior authorization gives your insurance company more power than your doctor. If your prior authorization is denied, you have three options: pay out of pocket (not realistic); give up (this happens 80% of the time); or the doctor can go to bat for you.

One doctor says that she must get approval 95 percent of the time. Another doctor notes that she has four full-time employees whose sole focus is on obtaining prior authorization for medications to treat Crohn’s disease and ulcerative colitis. A frustrated pediatrician says, “I end up talking to someone who’s not even a physician—people who couldn’t pronounce the names of the drugs I was trying to prescribe.” Another says that the insurance company was giving her a hard time getting approval for chemotherapy for a patient diagnosed with lymphoma. “I was so emotionally exhausted. And that was just one patient.” By one estimate, the U.S. spends about $35 billion a year on the administrative costs of prior authorization.

Decades ago, prior approval was used sparingly to make sure that treatments and long hospital stays were necessary. The idea was to save us money. Now, it’s devolved into a system where treatments are denied for no reason. Even everyday medications, such as test strips for blood sugar and ADHD meds, require insurance approval.

The way insurance companies profit is to deny care. If they deny or delay care, that’s money they get to keep. Prior approval only serves to enrich the insurance companies: Cigna made $5.2 billion in profit last year; Elevance made $6 billion; United Health care made $22 billion.

I have never been turned down by my insurance providers (Medicare plus a supplement). But I have no idea if my physician has had to suffer on my account.

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