Prior authorization is when insurers require doctors to request approval before covering certain treatments, usually forcing patients to try cheaper alternatives first. Insurers often deny newer, more effective medications in favor of older drugs, and sometimes insurance staff with no relevant expertise block specialists' decisions. Doctors aren't the problem here.
What are prior authorizations? Prior authorizations is what physicians, and sometimes diagnostic facilities and hospitals, have to do, um, in order to tell an insurance company that you need something. And in this example, we'll use medications. So, I have a patient that has a problem, and I prescribe Medication A to this patient, and the insurance company goes, "No. Medication A is not on our formulary. It's not on our list of medications that we cover." you need to try X, Y, and Z first. Okay, sometimes that's fine because the medication A is just like medication X, same class of medications, and I just picked this one and this one's also fine. The problem is that sometimes medication A is just expensive and the insurance company doesn't want to cover it because they want you to get a cheaper alternative first. And truthfully, sometimes a cheaper alternative is fine, but a lot of times a cheaper alternative is not as good. And medication A is expensive because it's new, it just came out maybe and doesn't have any generics, and Medication X that they want to cover has been out for a long time, which again is just a significant problem. If I'm a cardiologist prescribing cardiovascular medication for one of my patients and I now have an orthopedic surgeon who works for an insurance company denying my cardiovascular medication, who are you and what guideline are you following? It's like they— it's confirmation bias. It's like a lot of times the insurance companies just pick certain studies that they want in order to approve or disapprove medications to benefit them. So please don't get mad at your doctor. We are trying. It's not us.
