What Is Prior Authorization—And What Is It Really Doing?
By Contributor Seth B
On paper, PA is a pre-approval process. Before a treatment, test, or medication can be administered, a medical provider must justify its necessity to a commercial insurance company. The carrier then reviews the request and decides whether to allow it. But in practice, it’s a labyrinth.
- A single PA request can require 15–60 minutes of paperwork, phone calls, appeals, and documentation—all for one patient, one procedure.
- Some practices report hundreds of hours per month spent on PA-related tasks, pulling nurses and physicians away from actual care.
- Delays stretch from days to weeks, even for urgent treatments like chemotherapy or post-operative pain management.
- Denials are often based on non-clinical factors, like whether a box was checked properly or which CPT code was used, not medical appropriateness. The goal is not to reject care—it’s to wear you down until you stop asking.
🧠 The Psychology of Delay: When Bureaucracy Becomes Strategy Commercial carriers have mastered a paradox: create a process so tedious, so opaque, that denial becomes redundant. Why say “no” when you can say “try again”—until the physician gives up? This is the strategy of procedural attrition:
- Complexity as a Weapon: The forms are confusing by design. There’s often no standardization, with each carrier—and sometimes each plan—using its own requirements.
- Human Bottlenecks: Phone lines are jammed. Fax numbers bounce. Portals glitch. Nobody answers. The system is alive—but barely.
- Pseudo-Clinical Reviewers: Requests are often evaluated not by doctors but by outsourced staff following scripts. Some never even consult the medical records.
- “Fail First” Protocols: Before approving a treatment, carriers often require patients to first try—and fail—cheaper alternatives, even when medically inappropriate. It’s not about denial. It’s about exhaustion.
🩻 Medical Consequences: When Delay Becomes Damage Every day lost to PA isn’t just administrative—it’s a day a patient doesn’t get the care they need.
- A cancer diagnosis delayed by a denied PET scan.
- A diabetic patient denied access to a glucose monitor until they “prove” they need it.
- A child with epilepsy forced to fail two cheaper drugs before receiving the one their neurologist knows will work. This is rationing, not reform. And the human toll is staggering. In a 2021 survey by the American Medical Association:
- 93% of physicians reported delays in care due to PA.
- 30% said PA had led to serious adverse events for patients.
- 16% linked PA to hospitalization.
- 9% reported permanent harm. In other words: this isn’t about paperwork anymore. It’s about survival.
🕴️ The Corporate Logic: Control Without Accountability Why are carriers so invested in this system? Because it gives them control without consequence.
- They’re not denying care outright, so they avoid regulatory scrutiny.
- They’re not making clinical decisions, so they avoid liability.
- They couch the process in “cost containment,” so they appeal to employers and shareholders. It’s healthcare theater: the illusion of oversight without the burden of responsibility. And this theater is profitable. Every delay saves money. Every procedural hurdle increases the chance that a provider drops the request or a patient pays out-of-pocket. It’s a silent tax, levied in suffering.
📊 The Misleading Metrics PA is often defended with vague data: “It improves outcomes,” “Prevents overuse,” “Controls spending.” Let’s unpack that:
- There’s limited empirical evidence that PA improves clinical outcomes.
- Most cost savings come from avoided treatments, not better ones.
- Administrative costs to practices—over $20 billion annually—far outweigh any “efficiencies” gained.
- Carriers rarely publish transparent audits of their PA outcomes. In short: it’s a “cost containment” strategy that shifts the cost—onto patients, providers, and the system itself.
🔍 The Bigger Picture: Bureaucratic Gaslighting Prior authorization is part of a broader pattern in American healthcare—one that centers around misleading narratives.
- “Managed care” isn’t managing care—it’s managing cost avoidance.
- “Utilization review” isn’t reviewing use—it’s stalling access.
- “Evidence-based medicine” is often weaponized to deny care that falls outside rigid formulas. It’s not enough to call PA inefficient. It’s a systematic misrepresentation of access. An engineered friction point.
📣 What Can Be Done? Policymakers are starting to pay attention. The “Improving Seniors’ Timely Access to Care Act” passed the House with overwhelming support in 2022, aiming to streamline PA in Medicare Advantage plans. But commercial carriers still operate largely unchecked. Here’s what reform could look like:
- Standardized PA protocols across carriers.
- Real-time electronic approvals for routine procedures.
- Automatic approvals for evidence-based treatments.
- Transparency in denial data and reviewer credentials.
- Penalties for delay-related harm. Until then, practices will keep fighting—and patients will keep waiting.
🧨 Conclusion: Denial by a Thousand Paper Cuts Prior authorization is not a speed bump—it’s a maze. Not an oversight—it’s a tactic. Not a safeguard—it’s a smokescreen. And like all misleading systems, it thrives on the perception that it’s normal. It’s time to call it what it is: a coordinated barrier to care, engineered not through denial, but through deliberate dysfunction. Because when the system is this broken, fixing it isn’t enough. Exposing it is the first ste
