Prior authorization — largely unknown until a few years ago, it’s quickly become one of those insurance terms that’s sure to give any medical provider or patient an instant headache.
Insurance companies require prior authorization for certain procedures, tests and medications. In order to approve treatment, the insurance company puts a hold on a claim while it is reviewed on its end before an approval or a denial is issued. This process was implemented to keep costs down and limit egregious claim approvals, all to the benefit of the insurance company.
As our system stands, insurance companies are a necessary part of our health care model, but at the end of the day, they’re for-profit entities. Their costsaving measures tend to outweigh what’s best for patients, and that’s when problems arise. Unfortunately, it’s happening all too often.
As a physician, I can attest that prior authorization has been a pain point for me — and, more importantly, for my patients — for many years. Which treatments require prior authorization isn’t always clearly spelled out, leaving physicians and patients to navigate a minefield of authorization-related delays and denials. Physicians and staff routinely spend hours on administrative tasks related to prior authorization, like submitting documents and following up on approvals, spending precious patient time listening to the insurance companies’ hold music. It’s frustrating, and can be dangerous as delays for patients with time-sensitive treatment plans can be life threatening.
Now, AI has crept into the prior authorization process. Patients have long been denied access to medical care as a result of prior authorization reviews, but these days, a computer may be issuing the denial. There’s not even a human involved in the process, much less a doctor. This is unacceptable.
The tide is turning, but there’s still much work to be done: Prior authorization has been recognized as an issue by lawmakers, and in May of this year, the Ensuring Transparency in Prior Authorization Act was signed into law. When it goes into effect in 2025, the law will establish more stringent and transparent timeframes and policies for prior authorizations. Insurance companies will be required to modernize their authorization systems, publish prior authorization requirements online and require licensed medical professionals to make denials, just to name a few.
This is a win for all Oklahomans. It ensures patients receive timely, appropriate treatment, as determined by medical professionals. Plus, it allows physicians — many of whom are already stretched thin, especially in rural areas — to spend more time treating patients and less time on administrative runaround.
At the end of the day, our patients trust medical professionals with their lives, not insurance companies. Red tape has no place in health care.
Editor’s Note: Edgar Morris Boyd, M.D. is an otolaryngologist in Muskogee, where he practices at the Warren Clinic Saint Francis Health System. He is president of the Oklahoma State Medical Association.
