Prior authorization was designed as a cost-control mechanism — a checkpoint to ensure that expensive treatments are medically necessary before they’re approved. In theory, reasonable. In practice, it has become one of the most significant sources of friction, delay, and distrust in the patient-physician relationship.
I want to describe what it looks like from the inside, because I think most patients encounter the effects without seeing the machinery.
What actually happens
A physician recommends a treatment — a medication, an imaging study, a procedure. The insurer requires a prior authorization before it will cover the cost. The physician’s office submits documentation: clinical notes, diagnosis codes, evidence that other treatments have been tried and failed. The insurer reviews the submission — often through a third-party company using algorithmic criteria — and approves or denies it.
The review is conducted by someone who has not examined the patient, may not be a specialist in the relevant area, and is working from a set of criteria that may not match the clinical literature.
The denial problem
What most patients don’t know is that a substantial percentage of denials are overturned on appeal. The denial wasn’t medically justified — it was administrative. The treatment was appropriate; the paperwork wasn’t.
What also most patients don’t know is that the majority of those overturnable denials are never appealed. The practice doesn’t have the bandwidth. The patient doesn’t know they can. The revenue isn’t worth the hours of staff time. So the treatment doesn’t happen.
What this does to the relationship
When I recommend something and it gets denied, I have to explain to my patient that my clinical judgment has been second-guessed by someone who hasn’t met them, using criteria I can’t fully see. Then I have to ask them to wait while I fight for what I already believed was the right call.
The erosion of trust this creates isn’t directed at me, exactly. But it’s directed at the system — and I’m part of the system. That has consequences for whether patients follow through, whether they trust the next recommendation, whether they engage with their care at all.
This is a policy problem that requires a policy solution. In the meantime, I try to be as transparent as possible about the process — because patients deserve to understand what’s actually happening to them.