Navigating the Prior Authorization Maze

While intended to ensure appropriate and cost-effective care, prior authorizations often create significant barriers to patients and caregivers. This can impede timely access to necessary medical interventions, like anti-seizure medications.

The challenges of prior authorizations

Recently, I was reminded of this barrier in the process of accessing an essential medication for my son, who has severe non-verbal autism and Epilepsy. My son has been on 2 seizure medications for over 10 years, and when I went to the pharmacy to pick it up, I was told that Medicaid was denying the medication and I should call them to find out why. After calling four different numbers with Medicaid, I was able to learn that to receive the medication, prior authorization needed approval.

Prior authorization is a process by which insurers require healthcare providers to obtain approval before proceeding with certain treatments, procedures, or prescriptions. Typically, this requirement is triggered for medications or services that the insurer deems as potentially costly, non-formulary, or medically unnecessary.

On the surface, prior authorizations may seem like a prudent measure to control healthcare spending and promote optimal use of resources. However, in practice, as in our case, they often result in delays in care, administrative burdens, and added stress for patients and healthcare providers alike. 

Understanding what information is required, how to submit it, and whom to contact for updates can be overwhelming, particularly for individuals already dealing with health-related stressors.

A challenge for many families

I had to speak to the pharmacist multiple times to help get this medication approved through Medicaid. The process involved making multiple calls to the neurologist.

I had to request that their office submit prior authorization and then call back to verify that approval had been received. I then had to call the pharmacist back and ask them to contact the Medicaid pharmacy helpline to troubleshoot the issue of approving the medication.

3 days after beginning this process, I left the pharmacy with medication in hand. As I walked out, I wondered about others facing these same burdens. 

What about parents with multiple jobs who might not have the time to dedicate to the process? The barriers imposed by prior authorizations can disproportionately affect vulnerable populations, including low-income individuals, the elderly, and those with limited health literacy.

For these patients, navigating complex administrative processes may be particularly challenging, further exacerbating disparities in healthcare access and outcomes.

The impact on healthcare providers and patient care

Additionally, prior authorizations can strain the resources of healthcare providers, diverting time and energy away from direct patient care. Physicians and their staff must dedicate valuable time to completing paperwork, obtaining approvals, and advocating for their patients, which can detract from their ability to deliver timely and comprehensive care.

Advocating for solutions

Recognizing the adverse impact of prior authorizations on patient care, advocacy efforts have emerged to reform the process and mitigate its burdens. Healthcare professionals, patient advocacy groups, and policymakers are increasingly calling for measures to streamline prior authorization requirements, improve transparency, and expedite the approval process.

Tackling these challenges needs everyone's efforts, from insurers and healthcare providers to policymakers and patient advocates. We need to put patient well-being at the forefront and ease the hassles of prior authorizations so that everyone can get the care they need right when they need it.