Prior Authorization Can Slow Down Treatment — But You Can Fight Back

Few readers would be surprised to read that Americans are dissatisfied with their health care coverage — an outrage that the December 2024 assassination of UnitedHealthcare CEO Brian Thompson arguably brought to a head.

But many quieter frustrations remain. One of the largest, as evidenced by recent legislation attempts, is prior authorization: a process that requires care providers to seek approval from insurance companies before offering certain services or medications.

What is prior authorization — and how is it a problem for patients?

If you’ve ever been told by your doctor that they needed to wait for approval to move forward with treatment, chances are you’ve experienced prior authorization firsthand. Prior authorization has its origins in the 1960s, when Medicare and Medicaid legislation prompted the implementation of utilization reviews. Its purpose is to cut costs for insurers by limiting unnecessary hospital stays and spending.

However, the requirements for prior authorization have since changed, becoming a thorn in the side of physicians trying to help their patients.

"I spend more time trying to figure out how I need to get this medication approved than I do seeing the patient and making a diagnosis and writing the prescription," said pulmonologist Dr. Gabriel Bosslet in an interview with The Guardian. "This didn’t really happen five or seven years ago."

Delays in prior authorization can in turn delay treatment — and therefore relief — for suffering patients. (While the majority of prior authorization requests are approved, the share of denials is increasing, jumping from 5.8% in 2021 to 7.4% in 2022, according to an analysis of Medicare Advantage insurer data from the Kaiser Family Foundation or KFF.)

As a result, several states have passed laws aimed at reducing prior authorization timelines and increasing transparency with patients throughout the process.

In addition, a federal-level bill was recently reintroduced with the goal of expediting prior authorizations for patients on Medicare Advantage plans. Additionally, the Centers for Medicare and Medicaid Services (CMS) finalized a rule to improve the prior authorization process last January.

How to improve your chances of quick prior authorization

As a patient, prior authorization is both important for your treatment — and, unfortunately, largely out of your control. Most of the steps that can be taken to ensure speedy authorization must be taken by your provider, and include ensuring all the information on your file is correct (and spelled correctly) and submitting requests electronically to streamline communication and save time.

However, if you’re a patient on the wrong end of an authorization request denial, you do have options.

According to the KFF data, fewer than 10% of denied authorization requests were appealed in 2022. And yet, KFF says, more than 4 in 5 (83.2%) of such appeals that are made succeed in overturning the denial, at least partially. Which is to say, it’s worth trying.

If you’re denied a prior authorization (which can also be called a preauthorization, preapproval or precertification), you can appeal the decision in writing. If you contact your insurance company directly, they should have information about where (and how) to submit the appeal. They may offer a fax number or a physical mailing address.

To increase your chances of success, it’s important to review your health insurance policy information as well as the reason the authorization was denied in the first place. (If you’re not sure, you can ask these questions when you call your insurer for the appeal instructions.)

Once you have that information, you can ask your provider to offer diagnostic notes as well as their reasoning for requesting the denied treatment. In your appeal letter, you can also include a personal statement about how the treatment would improve your quality of life or improve your health and abilities.

You may have to wait up to a month to receive an answer, which may spell a further delay in treatment. Still, given how often appeals are successful, it might be a worthwhile process. The worst thing your insurer can say is no — which, after all, you’ve already heard.