The Prior Authorization System Is Costing Lives. Here Is How It Works and What You Can Do.

 Your doctor recommends a medication. Your insurance company says no. You have to wait weeks or months while the insurance company decides whether your doctor's medical judgment is acceptable to them.


This is prior authorization. It affects 93% of physicians and is responsible for documented patient harm and death.


**What prior authorization actually is**


Prior authorization is a requirement that your insurance company approve a medical service, test, medication, or procedure before you receive it. In theory, it is a cost-control mechanism designed to ensure appropriate care. In practice, it is a profit mechanism — every denied or delayed authorization saves the insurance company money.


The American Medical Association surveys physicians annually on prior authorization. In their 2023 survey: 93% of physicians reported that prior authorization caused delays in care. 82% reported that it sometimes led to patients abandoning recommended treatment. 34% reported that it had led to a serious adverse event for a patient in their care.


A "serious adverse event" includes hospitalization, permanent disability, or death.


**How the system works against you**


Insurance companies use prior authorization algorithms to deny claims at scale. A physician submits a request. An algorithm reviews it. The algorithm denies it. A human never looks at it until the appeal.


UnitedHealth Group used an AI algorithm called nH Predict to issue prior authorization denials for post-acute care. In 2023, a class action lawsuit alleged the algorithm had a 90% error rate — meaning 90% of the denials were overturned on appeal. But most patients never appealed. They simply did not receive the care their doctor ordered.


**What you can do**


First, ask your doctor to document medical necessity in the specific language the insurance company uses. Insurance companies train their reviewers to look for specific clinical terms. "Patient requires" is weaker than "Medical evidence supports the necessity of X as the clinically appropriate treatment for Y condition as defined by [specific clinical guideline]."


Second, request a peer-to-peer review. This is your doctor's right to speak directly with the physician reviewer at the insurance company. Studies show peer-to-peer reviews succeed significantly more often than written appeals alone.


Third, if your situation is urgent, request an expedited review. The ACA requires urgent reviews to be completed within 72 hours. Document that you made this request in writing with a date.


Fourth, contact your state insurance commissioner. Most states have enacted some form of prior authorization reform. Your state commissioner can tell you what rights you have under your state's law, which may be stronger than federal requirements.


Fifth, if a delay or denial causes you harm, consult an attorney who specializes in insurance bad faith claims. Insurance companies that act unreasonably in denying claims can be liable for damages beyond the value of the claim itself.


The prior authorization system was not designed to protect your health. It was designed to reduce the insurance company's costs. Your job is to understand that and navigate accordingly.


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