糖心原创

By Madeleine Burry
July 8, 2025 | VOLUME 3, ISSUE 2

If you have health insurance or work in health care, you鈥檝e undoubtedly run into the need for prior authorization (PA)鈥攖he necessary approval of certain nonemergency treatments, such as medications, surgery, or an MRI, before they are administered.

PA was created to 鈥渆nsure appropriate care and control costs,鈥� said Anita McGlothlin, Senior Director of Economics and Health Policy of GO2 for Lung Cancer, a patient advocacy group. But the perhaps well-intentioned tool鈥攁nd the denials associated with it鈥攐ften becomes a time-consuming, harmful hurdle to health care.

“I have a great example of that,” said Anthony Izzo, DO, FAAN, FAASM, Chief Medical Officer and Executive Vice President of Massachusetts-based Community Neuroscience Services & Community Specialty Services.

Dr. Izzo had a patient who had tried nearly every oral narcolepsy medication available without results. The physician’s next step was to prescribe the central nervous system depressant sodium oxybate. This is neither a cheap medication nor one to take without due consideration given its potential side effects.¹ But Dr. Izzo and his patient felt it was the right fit; her severe cataplexy, a type of muscle weakness affecting people with narcolepsy, often in response to strong emotions, had locked her away from the world. She was unable to work, drive, or engage in everyday activities, Dr. Izzo said.

“Her insurance would not approve [the treatment]. They flat-out denied it,” he said. The denial was overturned only after the patient had hired a lawyer. She is now able to work and, after passing her driver’s exam, can drive to work daily.

“Her life is absolutely different than it was before taking this medication,” Dr. Izzo said. That’s despite her insurance company—not because of it.

While a patient is waiting for PA approval, they may or may not be able to schedule an appointment; it depends on the policies of a facility or practice, as well as those of specific departments, McGlothlin said. That is, a hospital or health system may allow scheduling prior to approval, but the department performing a scan might not.

Bottom line: PA paperwork is a preliminary hurdle that can lead to treatment delays in a number of ways, McGlothlin said.

Chasing down approvals

For patients, the need for PA can be frustrating, stressful, and potentially have a negative effect on their health. For clinicians, PA is a cumbersome process requiring endless phone calls, forms, and even faxes.

At Dr. Izzo鈥檚 practice, dealing with PA is woven into the day-to-day activities. 鈥淎ll of my staff members are trained to do it,鈥� he said. The medical secretaries at his practice handle imaging and sleep PAs, while medical assistants tackle medication PAs.

Practices across the country submit an astounding amount of PA requests: On average, each physician at a practice submits 39 requests per week, which takes about 13 hours a week, according to the AMA. That鈥檚 more than 2,000 PA requests per year for a single physician.

But submitting the PA request is only the first step; often, requests are denied.

Here’s a common scenario, according to Dr. Izzo: An insurance company will deny use of a CPAP machine for a patient, giving the explanation that while the practice provided a sleep study showing the patient does have sleep apnea and documenting its severity level, it failed to share the raw data. The insurance company, Dr. Izzo said, wants to get granular with that data to ensure he’s not claiming the patient has sleep apnea when they don’t.

“I think [that] would be negligent of me as a doctor to walk around telling people they have diagnoses they don’t actually have,” he pointed out. Plus, on top of all that, 9 times out of 10, his office already did send raw data—so the next step is to fire up the fax machine to send information over a second time.

A report from the US Department of Health and Human Services (HHS) Office of Inspector General found that one 1 of every 8 requests for PA that ran through Medicaid managed care organizations was denied.⁵ Together, the managed care organizations examined in this investigation enrolled 29.8 million people. In 2023, 20% of claims on the Affordable Care Act Marketplace were denied, with substantial difference in denial rates by insurer and state, per research from KFF, a health policy research organization.⁶

Sometimes the reason for a denial is clear. Often, it is unclear. For denials for in-network claims, KFF research found that “Other” was the most commonly cited explanation, responsible for 34% of denials. Some denials can be due to coding misalignment or inconsistencies—a bureaucratic matter.⁷

But denials can be incorrect: Medicare Advantage Organizations (MAOs) denied 13% of PA requests that should have been covered, according to the HHS Office of Inspector General.⁸

When claims are denied, patients or providers can request an appeal, which can be expedited for urgent care scenarios, as with lung cancer, McGlothlin said. Then, if the denial is upheld, the next step is an external review.

But many patients aren鈥檛 equipped to file these appeals. 鈥淚t鈥檚 complex,鈥� McGlothlin noted. Plus, patients may not even know their right to navigate their way through the process.

Appeals can be effective, but they also can lead to inequity. KFF found that 82% of appeals submitted to MAO insurers in 2023 were partially or fully overturned, while only 29% of appeals submitted to traditional Medicare were overturned in 2022.⁹

Losing hope, abandoning treatment

Dismissing PA as a paperwork nuisance downplays its impact on health. In fact, in the previously mentioned 2024 AMA survey, 29% of the practicing physicians said that PA 鈥渓ed to a serious adverse event for a patient in their care.鈥�³

Insurance companies often require patients to try several medications and treatments before approving the one that the clinician recommends, which is known as step therapy. 鈥淲e have to demonstrate that the patient has either failed due to lack of efficacy or intolerable side effects [while taking insurance-approved options] first before they can access the more effective, easier-to-tolerate medication,鈥� Dr. Izzo said.

That can be risky for patients, he said, as some medications have dangerous side effects. The AMA survey found that 77% of providers report ineffective initial treatment due to PA.

PA can sometimes lead to patients abandoning treatment, according to 82% of the physicians surveyed by the AMA. Similarly, an American Society for Radiation Oncology survey of radiation oncologists found that an average of 1 in 10 patients abandon treatment owing to PA.¹⁰

Plus, spending time on paperwork and justifying medical decisions means less time with patients, per the AMA. 鈥淧roviders, especially in rural settings, are overwhelmed. They spend hours each week on phone calls, portal submissions, appeals,鈥� McGlothlin said. 鈥淲e hear from physicians and nurses who are pulled away from direct patient care to chase down approvals for services.鈥�

So what鈥檚 next?

You鈥檒l find few defenders of PA, which obstructs care and is a headache for most.

With PA, 鈥渋nsurance companies are practicing medicine without a license and dictating to physicians what they can and can鈥檛 do,鈥� Dr. Izzo said. 鈥淲e鈥檝e lost sight of the patient and what鈥檚 best for them,鈥� he added.

But reforming PA is in the works; some progress is being made. For instance, about 100 bills are winding their respective ways through state legislatures across the country, according to the AMA. Some proposed legislation is gold card laws, which exempt providers from PA if they have high approval rates for PA requests. Insurance companies have also been enacting these programs, per Aimed Alliance, a nonprofit health policy organization.¹¹

Another hopeful sign is that beginning in 2026, the US Centers for Medicare & Medicaid Services will require Medicaid Advantage plans to reply to urgent PA requests within 72 hours and standard ones in seven days (the current standard is twice as long).^12,13

When it comes to PA reform, “we believe that the system should support and not obstruct life-saving care,” McGlothlin said.

It’s more than a policy issue; it’s a patient safety concern, she said. Removing barriers to care provides patients with easier, speedier access to effective, clinician-recommended treatments.