Ways to play the prior authorization game

There is nothing more frustrating to physicians than knowing a patient needs a certain diagnostic test or medication and having them not be able to get it because their health insurance company won’t cover it. All too often, many services require prior-authorization (PA).

It wouldn’t be so bad if the insurance companies made the guidelines they use to make these determinations readily apparent to those practicing medicine. However, these guidelines are created by the insurance company (with a main goal being cost containment rather than evidence-based medicine), unavailable to treating clinicians, and often they use decades-old recommendations. We are often left to predict the insurance company’s decision.

Many of us feel that it is like playing an epic game where we try to give our best care to our patients, while the insurance companies deny as many tests as possible to increase their profits. The loser of this game is not the one who was able to get the least amount of services covered or earned the least money. Rather, it is the patient: delayed diagnoses/treatment, denied tests, forced to use less effective medications based on formularies developed by insurance companies using their own guidelines, and footing increased costs.

How can this prior-authorization game be played for better odds of winning?

While these tips may help get some services covered, they often still do not work. The insurance companies hold a lot of power over these medical decisions. The most important thing is to keep fighting the ones we don’t medically agree with. The day we all quit the battle is the day we lose the game and big insurance companies win and determine medical care. We must remain diligent in our fight for optimal clinical outcomes in all and each of our patients.