By Lauren Sausser, who covers health care across the South as a member of KHN’s Southern Bureau. She is based in Charleston, where she previously spent nine years covering health care at The Post and Courier. Originally published at Kaiser Health News.
When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.
As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.
But her MRI appointment kept getting canceled, Chestnut’s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn’t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut’s health insurer deemed the MRI medically unnecessary and would not authorize the visit.
“On at least four or five occasions, she called me up, hysterical,” Roux said.
Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.
Though Roux doesn’t fully blame the health insurer for his mother’s death, “it was a contributing factor,” he said. “It limited her options.”
Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.
Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.
Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.
So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.
“The prior authorization system should be completely done away with in physicians’ offices,” said Dr. Shikha Jain, a Chicago hematologist-oncologist. “It’s really devastating, these unnecessary delays.”
In December, the federal government proposed several changes that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment through March 13.
Although groups like AHIP, an industry trade group formerly called America’s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don’t go far enough.
“Seven days is still way too long,” said Dr. Julie Kanter, a hematologist in Birmingham, Alabama, whose sickle cell patients can’t delay care when they arrive at the hospital showing signs of stroke. “We need to move very quickly. We have to make decisions.”
Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days. In Michigan, insurers must report annual prior authorization data, including the number of requests denied and appeals received. Other states have adopted or are considering similar legislation, while in many places insurers regularly take four to six weeks for non-urgent appeals.
Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to delays in cancer care in Pennsylvania, meant sick children in Colorado were more likely to be hospitalized, and blocked low-income patients across the country from getting treatment for opioid addiction.
In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.
Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.
Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.
Conlisk thought her mom’s case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn’t show on the day Conlisk was told it would. No one notified them the ride hadn’t been pre-authorized.
The time it takes to juggle a prior authorization request can also perpetuate racial disparities and disproportionately affect those with lower-paying, hourly jobs, said Dr. Kathleen McManus, a physician-scientist at the University of Virginia.
“When people ask for an example of structural racism in medicine, this is one that I give them,” McManus said. “It’s baked into the system.”
Research that McManus and her colleagues published in 2020 found that federal Affordable Care Act marketplace insurance plans in the South were 16 times more likely to require prior authorization for HIV prevention drugs than those in the Northeast. The reason for these regional disparities is unknown. But she said that because more than half the nation’s Black population lives in the South, they’d be the patients more likely to face this barrier.
Many of the denied claims are reversed if a patient appeals, according to the federal government. New data specific to Medicare Advantage plans found 82% of appeals resulted in fully or partially overturning the initial prior authorization denial, according to KFF.
It’s not just patients who are confused and frustrated by the process. Doctors said they find the system convoluted and time-consuming, and feel as if their expertise is being challenged.
“I lose hours of time that I really don’t have to argue … with someone who doesn’t even really know what I’m talking about,” said Kanter, the hematologist in Birmingham. “The people who are making these decisions are rarely in your field of medicine.”
Occasionally, she said, it’s more efficient to send patients to the emergency room than it is to negotiate with their insurance plan to pre-authorize imaging or tests. But emergency care costs both the insurer and the patient more.
“It’s a terrible system,” she said.
A KFF analysis of 2021 claims data found that 9% of all in-network denials by Affordable Care Act plans on the federal exchange, healthcare.gov, were attributed to lack of prior authorization or referrals, but some companies are more likely to deny a claim for these reasons than others. In Texas, for example, the analysis found 22% of all denials made by Blue Cross and Blue Shield of Texas and 24% of all denials made by Celtic Insurance Co. were based on lack of prior authorization.
Facing scrutiny, some insurers are revising their prior authorization policies. UnitedHealthcare has cut the number of prior authorizations in half in recent years by eliminating the need for patients to obtain permission for some diagnostic procedures, like MRIs and CT scans, said company spokesperson Heather Soules. Health insurers have also adopted artificial intelligence technology to speed up prior authorization decisions.
Meanwhile, most patients have no means of avoiding the burdensome process that has become a defining feature of American health care. But even those who have the time and energy to fight back may not get the outcome they hoped for.
When the ambulance never showed in July, Conlisk and her mother’s caregiver decided to drive the patient to the clinic in the caregiver’s car.
“She almost fell outside the office,” said Conlisk, who needed the assistance of five bystanders to move her mother safely into the clinic.
When her mother needed an ambulance for another appointment in September, Conlisk vowed to spend only one hour a day, for two weeks leading up to the clinic visit, working to get prior authorization. Her efforts were unsuccessful. Once again, her mother’s caregiver drove her to the clinic himself.
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The system is a disgrace. When I needed MRI for an injured shoulder, the insurance, which I pay each month to the tune of $1879, denied it. Me? I can afford it to so I paid for the $700 procedure myself. What about others?
But it takes action on our part, too. I switched voter registration a few years back in order to vote for Senator Sanders (for when the circus rolled into Florida during primary season). Of course, by then, the Democrat machine had shut his campaign down (first in IA with the Buttigieg debacle) and then the final nail in the coffin, SC.
So Biden was the presumptive nominee when the ‘race’ got to Florida. Nevertheless, I braved in person voting (remember COVID was racking up the kill count and we were still masking and washing our hands like raccoons given sugar cookies). Point being, going in person took personal conviction and no small measure regarding an unknown amount of risk.
Anyway, despite this small bow to the obvious, I don’t think anything really changes. Proof? The government could have put a stop to this absurd practice. They didn’t.
Why is that in NOT ONE single discussion I’ve ever read about the train wreck that is the American lack of healthcare system is that allowing everything such as Prior Authorization to minimum wage clerks changing Coding or some higher echelon bureaucrat disallowing experimental procedures recommended by doctors and desperately wanted by patients are de facto if not de jure examples of practicing medicine without a license.
If any of these CEOs, bureaucrats or clerks were actual doctors, they would lose their licenses the very first day of their practice.
Whatever happened to the California lawsuit against the corporate practice of medicine?
Great question. Anybody in the NC commentariat have any updates?
Will preface this comment by saying I am 200% behing a Single Payer system I have been watching New Amsterdam on Netflix and one thing that occurs to me is if we increase access to care then given the limited supply of Physicians (thanks AMA) won’t wait times increase just like in Canada and UK?
Your doctors probably spend a considerable amount of time on non patient stuff that reduces time for patients.
In Japan the wait time is negligible and the out-of-pocket costs are low. Here in the US, I’ve had a problem that is serious but neither fatal nor expensive since last September and will finally see a doctor for it in April, upgraded from “next November”. I have “good” employer-paid insurance with one of the premier teaching hospitals in the US. I found out the reason is that the specialists I need are short-staffed in all medical groups because they can make so much more in private practice doing unnecessary cosmetic procedures for the vain instead of treating boring normies. This was particularly annoying to me since I grew up with Tri-Care, which is single-payer for military families. I received excellent care with no BS from the day I was born until I aged out and was on my own.
And as another commenter noted, doctors and their staff waste enormous amounts of time on bureaucratic procedures that would go away with private insurance. One of the leading reasons younger doctors quit is that they are fed up with the paperwork and denial of care to their patients and that HMOs and the private equity groups that have been buying up independent practices and clinics have increased the workload and lowered the compensation to sacrifice patient outcomes on the altar of shareholder value.
if we increase access to care then given the limited supply of Physicians (thanks AMA) won’t wait times increase just like in Canada and UK?
I live in Canada.
Last time I saw a doctor, at the height of the COVID crisis, my own physician was booked for two weeks so I made an appointment at their after-hours clinic. Five hours from first phone call to seeing doctor. He immediately authorized an x-ray. I walked around the corner to a local hospital and got x-rayed almost immediately—it was late, so no line-up. Normally, I expect I would have wait an hour or more.
There can be long waits for non-emergency care but I think you have been hearing US medical insurance propaganda.
The anti healthcare for all crowd often trot out the “waiting time increase” in Canada and other countries bu they don’t know or say anything about the wait time being for procedures that can wait like hip replacement and the like.
Very misleading headline to this piece. There seems to be very little “reigning in” going on, and the prior authorization train seems to be rolling on like it always has.
I think you mean “reining” in, but perhaps it actually is very Freudian in that health care companies DO indeed reign as if they have some sort of unchallengeable divine mandate.
I suspect that the problem is complicated:
1. Over-prescribing procedures is a real problem
2. As the costs are rising and insurance companies have poor control over them, they resort to service denial.
3. With multiple entities with conflicting interests, what passes for rational control has the form of rule making by the government, with manipulation by conflicting lobbies and probably meager input from actual patients.
An example I have some info about: the charges for transporting infirm patients can be huge, and the rules for authorizing are arcane. A patient with no driver in the family and who needs to be helped through some number of steps is under tight and arbitrary rationing. Ambulance may charge ca. 1000 bucks, a service that require at least a week of prior reservation, 300, etc. Some services would help on the stairs and some not etc.
A better approach would be to get good statistical picture of such needs and medical benefits, and organize those services in a cost effective way.
One idea to address the high number of unnecessary procedures without delaying patient care with prior authorizations would be for insurers to randomly audit a small subset of physician recommendations after the fact. If audits turn up a high number of unnecessary procedures, an investigation could then lead to consequences for the physician. For example, the physician could be given a publicly available scorecard or patients could be informed that “this physician recommends a high number of unnecessary procedures” all the way up to “we will be denying claims from this medical provider starting on date X so you should switch physicians” or there could be other penalties for the physician.
But who would perform audits and issue score cards in the “multi-payer system”? Plus, there are other trade-offs, while increased procedures and unnecessary services increase costs, they have some marginal utility — unless outright fraudulent — so one should work both on costs and “over-use”.
In the examples I know, be it pneumonia or difficult birth, American hospitals strive to discharge patients as quickly as possible, because each day in the hospital costs many thousand dollars. But is there an objective reason why just staying in a hospital and recovering for extra 1 to 3 days costs so much?
I have one entire full time employee in my office who does nothing but sift through these authorizations every day. It takes an hour or so of my day to go over their work and get drugs or tests done for my patients. It becomes a triage – we have to prioritize these authorizations on who needs the meds or who is going to die without XYZ test. Yes, it is that bad.
It is very onerous. One small mistake – and your patient’s papers go to the bottom of the stack in some corporate office never to be seen again for another 2-3 weeks.
The sad fact is that more than 98% of these issues are approved “prima facie”. It is a complete and total waste of time.
None of this – absolutely none – was going on before Obamacare.
You wonder why there are no primary care providers? You wonder why you cannot get your labs back in a timely manner? You wonder why communication with your physician is a nightmare?
Look no further.
I have no answers other than to retire or quit accepting any insurance. Many primary care doctors have already gone down this road. Maybe MOST. This is an absolute disgrace – and none of our boards or organizations seem to care to do one thing about it except make it much worse every year.
Add to that the percentage of every patient visit that the doctor spends tapping away on a computer, which I am told is a requirement of the electronic records that everybody’s supposed to have. Whenever I’ve mentioned this to a doctor, s/he responds with a scowl and says something to the effect of “I really hate this” under his or her breath.
I spend as little time as possible in doctors’ offices, but I don’t recall this being an issue a decade or two ago. Is this another improvement wrought by Obamacare? That’s the rumor.
The system is absolutely horrid and clearly doesn’t work as a solution to solve a problem. There’s no appropriate amount of PAs to address the potential for overly expensive medical options being selected.
Don’t look at me please to propose an alternative solution but I’m sure many bright people lacking sufficient lobbying power have thought of promising ideas.
I am surprised nobody has raised the issue of malpractice insurance. I suspect many doctors order unnecessary tests because of the threat of a malpractice suit. I wonder how many malpractice insurers are also health “care” insurers. It seems a perfect “hedge”.
Single-payer seems to be the only option–in any country where you can trust your doctor and your government.
With the exception of orthopedic surgery, and obstetrics in certain states, malpractice insurance is a red herring issue.
I specialize in med mal insurance and have for over 20 years. I’ve been through multiple market cycles and I know how the hospitals and doctors choose and buy insurance. The cost varies enormously based on area and specialty. Difficult venues like Philadelphia, Dade and Cook counties have high costs. In addition, orthopedic surgeons and OB’s have high costs anywhere, and unattainable in those difficult venues (up into the $200k annual range, which is financially prohibitive for most). But most other specialties and areas have costs that are manageable and simply “cost of doing business.”
I have had hundreds or more conversations with doctors and hospital risk managers about med mal issues. I could probably count on one hand the number of times I’ve heard any claims about ordering extra tests or procedures based on concerns over med mal liability exposure. From what I’ve seen, I don’t think many unnecessary tests are ordered, and when they are it’s either for pure profit, or because a doctor has outdated views from when test XYZ was considered useful, but it no longer is.
Very, very few insurers overlap between health insurance and med mal liability. I cannot think of a single one offhand. There are thousands of commercial insurance companies and most of them have specific and narrow specialties. Health insurance requires claims processing on a scale that most other lines do not.
There are definitely major problems with our med mal system, but they cut in both directions – many genuinely injured parties get no compensation, while in a few venues the plaintiff lawyers make obscene profits. No justice for anyone. However, outside of a few counties (mentioned), this is not an economically significant issue for either cost of care or access. Instead, nefarious parties like to exaggerate it so profits can be increased. Don’t think med mal premiums will go down if a state change its laws to block med mal claims, and certainly don’t expect health service costs (doctor and hospital bills) to decrease in that scenario. That would be total fairytale land.
Lol no…
Mid career community practice General Surgeon here. I am extremely grateful to have a meaningful, job that pays well while being non-parasitical. But Defensive medicine is definitely a thing. It’s so ingrained you don’t even think about it half the time. For instance, you can clear a blunt trauma (e.g. car accident) patient for the vast majority of C-spine injuries with a clinical exam. Yet there is absolutely no way I’m taking you onto my service (admitting you after the ER) without a full pan scan (ct head, neck, chest, abdomen, pelvis, thoracic and lumbar spine) why? I’ve been burned once by a missed spinal injury on a teenaged car thief and got lucky. The cost of lifetime care alone for a young para or quad would annihilate my coverage max, 1MM*, the economic damages, pain and suffering, not to mention the teach-that-stupid-doctor-a-lesson damages would have me working for them for the rest of my natural life. No thanks.
How about other things? A wise older physician once said try to send anything complicated or greater than average risk to have a bad outcome to tertiary care (University hospital) not that they would do anything all that different but if something goes wrong then at least the family won’t have that question in the back of their mind. If you end up having to do it yourself at least you can say you tried to get them to a higher level of care. Unfortunately transfers take days and often don’t happen.
I could go on and on, but the bottom line is that physicians are constantly thinking about getting sued. And not without reason. Been sued 4 times. Three were complete BS and dropped. But I still had to go through the painful process. You can beat the rap but not the ride kind thing. Fourth time I was party to a genuine mistake but not the actual guilty party, there was no injury but they could smell the payday and sure enough everyone paid. At least I didn’t have to undergo public character assassination in court. That payoff follows me everywhere I go. I have to explain it every time I apply for privileges. Sorry I ever got involved. Should have sent him to tertiary care.
But to be honest defensive medicine isn’t the biggest resource suck. Social pathology is the real black hole. Between the knife and gun clubs, the druggies/alcoholics, the diabetics/smokers and bad eaters/morbidly obese it seems like there are barely any people in the hospital who didn’t play an integral role in bringing it on themselves. I bet it’s 10x better in Japan.
The big exception to this is old people. I see plenty of decrepit/demented nursing home denizens. My understanding is that in Europe the doctors decide when to stop wasting resources on the doomed or nonproductive. I guess that’s ok in theory, but when it’s your elderly mother most people want. Say in what happens.
This brings the greater truth. Resources are not unlimited. All societies ration care. Ours puts the patient in charge but constrains spending with insurance company approvals and ability to pay. Other societies ration care through bureaucracy and capacity constraints. Ours is less efficient but offers more flexibility.
I’m lucky in that I can cross subsidize with my bread and butter cases so I practice humane medicine (just did a complicated cancer operation on an illegal alien, hospital lost a ton, I’ll probably get $25/hr from emergency Medicaid when all is said and done. ($500 for what will probably total 20 hours of care).
Another uncomfortable fact, private practice is more productive but it’s going away. As a doctor in private practice I work way, way harder than my friends who are employed. I do it for the autonomy, but I have colleagues who do it for the money. Regardless, measured by RVUs it would take at least 1.5 probably 2, maybe 2.5 Kaiser docs to match my productivity. And I am famous for spending too much time talking to patients. Most new grads are prioritizing lifestyle over earnings so they seek employed jobs where they work less. (I won’t even get into how they are incentivized/bullied to put the system first by withholding care.)
*For context 10% of my aftertax income goes to malpractice insurance.
RE: Wait times in Canada
Wendell Potter, former communications executive at Cigna
https://www.cbc.ca/radio/asithappens/as-it-happens-monday-edition-1.5631285/this-former-u-s-health-insurance-exec-says-he-lied-to-americans-about-canadian-health-care-1.5631874
Let me clear this is a massively insidious issue that permeates the system. We live it daily with our daughter who has Crohn’s. We actually had an insurance person explain when they denied authorization for one of her surgeries that their policy is deny everything over a dollar amount and make the patient appeal (yes, recreational colon resections run rampant, oy). The basis is they know a certain percentage of patients will just give up.
How can the not be criminal?
Until 2/15/2000 I worked as RN in a program for newly diagnosed schizophrenic young adults. Our goal was to get them back to school, work or whatever they had been pursuing, before their first psychotic break happened, as fast as possible. Often they had retreated to live with family after the hospitalization and were on parents’ insurance. Several medications might have been tried, but often, the thing that worked, that the patient preferred*, was a long-acting antipsychotic injection. Good for a month or up to 3 months.
These were always under patent, obscenely expensive if out of pocket. Easily $1500/month. The older, cheaper meds were ineffective, with onerous side effects, some permanent, such that you don’t want to give these to a young person. Some of the new ones are not so pretty either. So by the time you find that thing that works for this patient, who is still understandably reluctant to believe they have this illness, they have maybe veered toward relapse a couple of times.
Prior Authorization, or PA, is needed for the shot, even if they had been taking the same med in pill form all the way back to the hospital. List all the reasons the ancient, nasty med didn’t work, or they want you try it first. Eventually the MD has to gird her loins and do battle with the plan doctor, in soft dulcet tones. (But maybe dreaming of C4 that night).
Then, minor miracle, the parents’ insurance pays, the shot is given, symptoms are ameliorated, patient goes back to work. Or school. Improvement all around. So much improvement that, after a few months, the patient wants more independence, moves out, gets a job, or goes to school out of state. They are beginning to feel more like themselves again. Maybe they buy a car.
Insurance changes then. Start over with the PA process. Now talking with Student Health Services at the school out of state, trying to help. If the patient comes home to visit family or still lives locally, you scrounge around in the med room for a sample, or a kit from another patient who is lost to treatment, during the weeks you are doing battle with the insurance company.
The Drug company rep offers a coupon. You go down that rabbit hole only to find that the HMO, with some convoluted language, says that their institutional pharmacy, is “not set up” for this kind of transaction. Now I’m calling other nurses in other programs, (buildings), other parts of the mental health center on the other side of town, to see if they have the right med in the right formulation, right dose, etc. Before the patient decompensates.
And if the patient’s resources are slim, no family, etc, it’s even harder. Therapists providing assistance like transportation to appointments, work rehab, getting signed up for Medicaid, help with college admissions, tuition assistance. Etc, etc.
I tell you PA’s are one of the circles of Hell.
*was willing to take
And this is one of those many reasons why people live on the streets self medicating with only god knows what.
Hmm, I vaguely remember that I got hit by the need for pre-approval when I had pneumonia thirty years ago. As If someone in an emergency would have had the physical, emotional, and mental ability to successfully maneuver through the rules. But that is the point, isn’t?
Fortunately(?), I was able to power through at home, and what with the lack of air, I didn’t have the energy to be worried about dying. It’s amazing how clarifying it was when getting through my next breath was a big deal.
I should have just called an ambulance and have just drop me off, but as I remember there was no guarantee that the insurance would have paid for it. So, I didn’t.
But my point is that this is not a new thing. It has merely spread throughout the industry.
Dr. Linda Peeno confesses to denials.
https://m.youtube.com/watch?v=zGKtROmiJL8