Mansell, Engel & Cole

How should policyholders approach prior authorization demands?

Among perhaps a handful of candidates marking insurance-linked subject matter that drives doctors in Oklahoma and nationally to veritable distraction, so-called “prior authorization” likely tops the list.

If you’re a policyholder, you likely know what that is. And if you’re an insured who has personally dealt with prior authorization, it has undoubtedly frustrated you, too.

The concept/practice is simply explained, to wit: An insurance company must approve a particular treatment or other doctor recommendation before it will pay for it. Absent that approval, well … look out. Policyholders across the country routinely confront shocking challenges from insurers that deny claims based on failure to garner prior approval.

A recent national article on prior authorization notes that, “In theory, it helps to protect patients and control costs.”

Candidly, and based on the feedback of legions of doctors and patients across the country, that claim is patently false. Research findings from the American Medical Association stress that about one-fourth of all doctors can point to resulting serious harm for a patient forced to wait for an insurer’s approval on already MD-recommended treatment. Moreover, many patients necessarily seek additional/emergency care while they await an insurance provider’s approval.

This, too, it flatly notable: Reportedly, about 33% of surveyed physicians need to employ working staff that concentrates only on prior authorization matters. That is a reality that firmly evidences materially spiraling outlays, not cost savings.

The above-cited article underscores the stark challenge of prior authorization for America’s millions of insured individuals. It notes that a policyholder simply must “stay on top of the process and reach out to your insurer and provider as needed.”

Oklahoma insureds and their brethren across the country have found that to be an easier-said-than-done proposition.

Questions or concerns regarding a prior authorization challenge can be directed to an established pro-policyholders’ insurance law legal team.

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