It can be frustrating to arrive at the pharmacy to pick up a new prescription only to learn your insurance company requires prior authorization.

Prior authorization is a requirement that a doctor, hospital or other healthcare provider obtain approval from a health insurance company before a specific drug, procedure or medical test will be covered.

“Health insurance plans are increasingly using prior authorization to determine what medical care we get,” said Kevin Brasler, executive editor of Washington Consumers’ Checkbook. “Certain drugs or classes of drugs, any elective surgery or medical imaging tests must be approved by the health insurance plan before you can go get that.”

The process can leave patients waiting for days to learn whether their insurance will cover a treatment, medication or diagnostic test.

Insurance companies said prior authorization ensures treatments are medically necessary, encourages the use of lower-cost alternatives when appropriate and helps prevent unnecessary spending and fraud.

According to AHIP, the national trade association representing the health insurance industry, “Prior authorization is an important safeguard used by both public and private payers to ensure patient care follows clinical guidelines. It helps reduce patients’ exposure to low-value, unsafe or inappropriate care.”

“One thing they do, for example, is say, ‘The doctor’s prescribed this expensive drug, we want you to try the less expensive drug first, before you can use the more expensive one,'” Brasler said.

He said patients are not required to simply accept an insurance company’s decision.
“The first step, if you’re denied under prior authorization is to ask the doctor to go to bat for you,” Brasler said.

According to an American Medical Association survey, doctors now juggle an average of 43 prior authorization requests per week.

“That’s what’s frustrating now, not just for patients, but for doctors,” Brasler said. “Surveys of doctors found they’re spending 15-plus hours a week, on average, just fighting these prior authorization battles for their patients.”

Most people do not appeal prior authorization denials. Fewer than 1 in 10 denied requests are appealed, according to a Kaiser Family Foundation analysis of data that Medicare Advantage insurers submitted to the Centers for Medicare & Medicaid Services between 2019 and 2022.

However, the AMA said more than 83% of appeals resulted in an insurance company partially or fully overturning the initial denial in 2022.