The Prior Authorization

The doctor said she needed the surgery. Put it in the chart. Wrote the referral. Sent it to the insurance company with the imaging, the labs, the clinical notes, and a letter explaining why this was medically necessary.

The insurance company said no. Not no-we-don’t-cover-this. No-we-need-more-information. Which is the same as no, just slower. The doctor sent more information. The insurance company needed it in a different format. Then they needed a peer-to-peer review — the doctor who examined the patient has to call a doctor employed by the insurance company who has never seen the patient and explain why the surgery is necessary.

The peer-to-peer was scheduled for a Thursday. The insurance company’s doctor didn’t call. Next available slot: two weeks. During those two weeks the condition got worse, which the insurance company used to argue the treatment plan needed reassessment, which required a new prior authorization. The process started over.

This is not a bug. This is the product.

The insurance company doesn’t deny claims. It delays them. Denying creates a paper trail, an appeal right, a lawsuit. Delaying creates nothing. The patient waits. Sometimes gives up. Sometimes pays out of pocket. Sometimes ends up in the emergency room, where the insurance company pays ten times what the surgery would have cost.

Three hundred million prior authorization requests are filed each year. Thirty-four percent are initially denied. Eighty percent of those denials are eventually overturned — meaning the insurance company knew the treatment was necessary. The denial was never medical. It was financial.

She got the surgery eventually. Four months later. By then the recovery took twice as long. She missed three months of work. She lost the job. The insurance was through the job.