The doctor’s perspective: Battling with insurers over prior authorization

Gary Price doesn’t need much prompting to relay his frustrations in securing pre-approval from insurers to treat patients.

Gary Price, president of The Physicians Foundation, says the prior authorization process is hurting patient care and burning out doctors. (Image: The Physicians Foundation)

Price, the president of the Physicians Foundation, recently retired from active practice. But he’s dealt with plenty of battles that have been time-consuming and exhausting. And he says the process is getting worse.

“Prior authorization, it's gone from being just an annoying role in taking care of patients,” Price tells Chief Healthcare Executive®. “It's become a full-fledged obstacle course that frustrates physicians. It delays patient care. It can even prevent good patient care. It lowers the quality of that care. And simultaneously, it's increasing the cost.”

Doctors and hospitals routinely cite prior authorization as either their top source of stress or one that is near the top of their list. With prior authorization, doctors must get insurers to sign off on treatments and medications for patients.

Insurers say the prior authorization process is designed to cut costs and curb unnecessary procedures. But providers say the process adds to their costs, since they have to hire additional staff to deal with authorization hassles.

Price recounts one battle with an insurer just before he retired. He wanted to get approval for pain medication after performing a routine procedure on a patient’s hand. The procedure took place on a Friday, and he recalls trying to get authorization for the medication on a Friday night before pharmacies closed, to no avail.

Eventually, after spending hours on the phone Saturday, he was able to get approval for the medication. Price also notes with irony that he originally sought approval for a generic drug, but the payer insisted on a name-brand prescription. It ended up being cheaper for the patient to pay for the generic drug out of pocket, but the patient had to wait almost a full day to get the prescription.

“This is a relatively minor pre-authorization issue compared to pre-approval for urgently needed surgery, or stronger pain meds for a cancer patient,” Price says.

Cancer doesn’t wait

While many specialists encounter hassles with prior authorization, Price says it’s a headache for primary care physicians as well. The Physician Foundation surveyed doctors about improving care, and 85% of primary care physicians said streamlining prior authorization will improve access to care. More than 9 in 10 doctors overall said prior authorization needs to improve.

Nearly all doctors (94%) said prior authorization has led to delays in patient care, according to a March 2023 survey by the American Medical Association.

Fumiko Chino, a radiation oncologist with Memorial Sloan Kettering Cancer Center, talked about her frustrations in getting approval from insurers during a KFF forum on prior authorization last week.

“Cancer biology doesn't wait for bureaucracy,” Chino said.

“And I think that's really the problem that we are faced with in our clinic, for people who have sometimes very fast-growing cancers,” she said. “Even when appropriate, prior authorization creates delays to care, and that can decrease outcomes and it can affect things like cancer survival.”

Some of the authorization battles range from cancer treatment to getting medication for pain management, she says.

Chino says she will think of alternative plans if an insurer denies her preferred treatment. She says she also will counsel patients that there’s a good chance their preferred treatment plan will be denied, to brace patients for disappointment.

“I will warn the patient in advance so that they don't have this peak of anxiety when they get a denial letter in the mail,” Chino says. “Often by the time they get the denial letter, it'll actually already have been approved on appeal because we're that efficient, but it helps reduce anxiety.”

Chino treats patients with cervical cancer, and she says she deals with payers that haven’t updated their templates for staging systems, meaning she has to put in outdated staging information, as opposed to current staging.

When doctors and health systems encounter a denial, they typically have to push harder and go through an appeals process. Doctors sometimes find they have to talk to a physician employed by the insurer that isn’t in their field.

Price recalls one clash with a payer where he was talking to a physician in a different specialty regarding a procedure for a patient. After a lengthy conversation, Price said the insurer’s doctor signed off on the procedure. As he was signing off, Price says the doctor asked him to spell the name of the procedure for the form.

“I spelled it out for her and hung up,” Price says.

• Read more: As Medicare Advantage plans rise in popularity, critics say authorization demands are rising

A radiation oncologist, Chino says she’s been on calls with payers where she has had to talk with doctors who don’t treat cancer, including family medicine physicians. In one positive recent development, Chino says that when she gets to an appeal process, she’s more often talking to a doctor in her field of radiation oncology.

“When I'm on the phone with a peer-to-peer trying to get a denial approved on secondary review, it is almost always with a radiation oncologist at this point,” she says, adding, “And the amazing thing is that when I'm a radiation oncologist talking to a radiation oncologist, I have not had them deny that care.”

Moral injury

Still, Price and other doctors say the prior authorization process consumes a great deal of time, and is a contributing factor to burnout. As Price says, it’s not just the tedious bureaucratic battles that wear down physicians.

“The burnout comes from the moral injury of having a process, like pre-authorization, that now takes away the physician's autonomy in making those decisions,” Price says. “But it doesn't take away the responsibility. That is a tremendous moral injury that goes on day by day, almost like paper cuts, as your ability to care for patients is constantly being impeded by these barriers.”

In the KFF forum, Chino echoed the sentiment that prior authorization battles lead to moral distress.

“When you're having to talk on the phone to someone who's having uncontrolled pain, and … your hands are tied due to prior authorization, it is leading to increased burnout, ultimately affecting the patients in negative ways and the physician workforce,” she said.

Chino said she’s encouraged by the federal government’s new regulations to streamline the authorization process from insurers. But she says the prior authorization process needs an overhaul.

“The whole process, I think, has some significant flaws,” Chino said. “I'd like to see it rebuilt from the ground up.”