What to Know: Prior Authorization

Prior authorization is a system insurance companies use to contain health care spending. Insurance companies apply prior authorization procedures to certain high cost medications. They do this to ensure that a prescription is medically necessary before deciding whether or not they will pay for it. Before a patient can receive a particular medication that they prescribe, Doctors must submit information detailing the patient’s specific need for a particular medication. Once the insurance company has received the Doctor’s justification, they will then approve the medication and a patient can receive their treatment.
Many states are currently introducing or revising legislation regarding prior authorization.
Through your grassroots advocacy as part of the 50 State Network— online and in-person — the Prior Authorization message of poor outcomes, inefficiencies, and higher costs can be conveyed to:

  • State elected officials and staffers (legislators and governor) • State-level committees and committee staffers
  • State Insurance Commissioners
  • State Medicaid Directors
  • Conventional media (television, newspaper, radio, magazines)
  • Unconventional media (blogs, Twitter, Facebook, discussion boards)

With your help in delivering the message to these audiences that prior authorization practices need to be streamlined, we can accelerate and strengthen the policies that are being implemented around the country.

What does patient-centric prior authorization legislation try to accomplish?

We are not against the idea of prior authorization, but rather the current way it is carried out. The process is lengthy, burdensome, and confusing. It is time consuming for physicians and frustrating for patients. The type of legislation we advocate for is aimed at implementing a streamlined and standardized process to submit prior authorization information, shortening the time between when a patient is prescribed a medicine and when they begin treatment.

Does the current system of Prior Authorization hurt patients?

Yes. Many patients incur a long waiting period before they begin necessary medications. Doctors are frustrated by the system and it is a tedious/confusing process to navigate. According to a recent study, the average physician practice devoted 1 hour of physician time, 13.1 hours of

nursing time and 6.3 hours of clerical time to the prior authorization process each week 1. A streamlined system would ensure timely treatment for patients and physicians’ time devoted less to paperwork and more to direct patient care.

 

What to say: Prior Authorization

  1. When a patient has to wait an extended period of time before beginning treatment, the patient, physician and public health suffers.
  2. The current system of prior authorization burdens the patient and physician leading to:
    1. Delayed treatment and prolonged illness
    2. Unstabilized care and the potential for permanent damage to occur
    3. Diminished physician time to meet with patients
    4. Patient frustration resulting in non-compliance and self-medicating
    5. Reduction in patient quality of life
  3. A standardized uniform system of filing prior authorization will alleviate the stresses the current process induces, allowing physicians to more promptly treat their patients, who can regain a higher standard of living.