Physicians are feeling increasingly burdened by prior authorization requirements, according to a recent Medscape report. This places significant pressure on independent practices, which often lack the resources of large health systems to manage the administrative burden.
"Without a doubt, the most dangerous trend in spine-adjacent fields is the challenge of prior authorization — which consumes endless time and phone calls with no guarantee of payment — and the questionable medical literature insurance companies cite to justify denying care," pain management specialist Eric Mehlberg, MD, told Becker's.
Klaud Miller, MD, an orthopedic surgeon and medical director of Windy City Orthopedics and Sports Medicine in Chicago, shared similar views on prior authorization with Becker's.
"Prior authorization does absolutely nothing except try to save insurance companies money once we finally give up. It does nothing for the patient or the doctor. It costs physicians time and money and only delays appropriate treatment," he said.
Dr. Miller described a frustrating process of spending valuable time navigating phone trees that, at best, end in conversations with payer-appointed "peers" who arbitrate prior authorizations with physicians.
A recent survey by the American Medical Association found that 65% of physicians do not consider these "peer reviewers" peers at all. Only 15% of respondents said that the payer-appointed peer "often" or "always" has the appropriate qualifications. More than one-third said that payer peers "rarely" or "never" have the expertise required to evaluate their patients' prior authorization needs.
"They substitute their judgment for my 50 years of clinical experience," Dr. Miller said. This lengthy process not only stretches physician labor but can also create a financial strain for independent practices.
"It certainly takes away any profit. If I have a peer review, I am making no profit on that case," he said.
In addition to the burden prior authorization places on physicians, Dr. Miller noted that it can lead to significant delays for patients, who may wait weeks to learn if a procedure or treatment is approved by their health plans.
"I mean, the patient's in pain for a longer period of time. I hear that all the time," Dr. Miller said. "So what happens? You have to give them narcotics. Well, we're not supposed to give narcotics because they're bad. So you know, what do you do? Treat the patient, give them the pain relief they need — because we're caught in a system of conflicts."
This frustration aligns with responses to the Medscape survey, where 86% of physicians reported that time spent processing prior authorization requests or appealing denials often delayed patient care. Another 61% said that patients frequently abandoned recommended treatments due to prior authorization delays.