Delayed care, higher costs: the prior authorization crisis.

Our current prior authorization is neither effective nor efficient, leading to weeks or even months of delayed care as patients wait on health insurers—in some cases even leading to patient death.

Physicians and patients across North Carolina agree: our healthcare can’t wait. Join our campaign to reform an unnecessary system that harms patients.

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What is prior authorization?

According to the American Medical Association, prior authorization (sometimes called preauthorization or precertification) is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.

Delays in care have human and financial costs.

When insurers say “no” to care that physicians and patients have already agreed on in order to protect their own budgets, it leads to costly and dangerous delays that have real impacts on patients’ ability to receive high-quality treatment and may leave them on the hook for thousands or even tens of thousands of dollars in unexpected medical debt.

The Frustrating Prior Authorization Process

What are the real costs of delay?

  • $1.8 billion+ annual cost to the healthcare system
  • 575+ hours per year spent by physicians on paperwork instead of helping patients
  • $2,000+ average higher costs to patients when care is denied

Delays lead to worse health outcomes, and sometimes the death of a patient.

After diagnosing a NC man with treatable bile duct cancer, the physician ordered a standard treatment for this patient. One week later, the insurance company requested a peer-to-peer meeting to discuss the treatment plan. Despite the standard-of-care plan, the insurance company stated that the prescribed regimen was not on its treatment algorithm and would not be approved.

The physician continued submitting three different care plans and had multiple peer-to–peer conversations with the insurer. Each standard care plan was denied by the patient’s insurance. This back-and-forth process took over one month, during which the patient received no care for his aggressive cancer. As a result, the patient’s condition worsened to the point that he was no longer eligible for treatment and had no options remaining besides end-of-life care.

So how do we reform the system?

  • Minimum standards for clinical review criteria
  • Physician consultation requirements during clinical reviews
  • Timely decision requirements during initial reviews and appeals
  • Continuity of care provisions to ensure patients don’t go without treatment
  • Limits on retrospective denials on treatment that has already occurred
  • Transparent plan language that helps patients and physicians understand what is and isn’t covered

Fight delayed care and higher costs. Take action for prior authorization reform NOW.

Join our campaign to reform a broken and unnecessary system that harms patients.

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