The Prior Authorization Process is Needlessly Complex

May 1, 2017
Melissa Young, MD

There are several redundant questions and processes when trying to obtain a prior authorization. It needs to be simplified.

Many man-hours are wasted in medical offices on paper pushing and unnecessary phone calls.  Many of them are related to obtaining prior authorizations.  I understand trying to curtail costs and ensuring patient safety and adhering to step-therapy based on current guidelines.  However, some simple steps on the parts of insurance companies and pharmacy benefit managers will eliminate a lot of wasted time for both the physicians' staff and the plans' employees.

For example, when we prescribe branded diabetes medications, one of the first questions that is asked when we do a prior authorization is "Has the patient tried metformin?" Granted, if the patient is new to the plan, they may not have his medication history on file yet, but if the patient has had the plan for a while and has been getting metformin, then they presumably have in his file that they are paying for metformin.  Also, once a drug has been approved, why do we need to get it approved again in 12 months (sometimes as soon as six)?

Let's say the concern is safety, then the only question should be "Since initiating therapy, has the patient developed a significant adverse reaction or a contraindication to the drug?" Why should we start from scratch, answering "what is the patient's diagnosis" and "has patient ever tried drug x?" when we answered those questions once before?  The answers aren't going to change.

Same thing with testosterone.  We need to answer if the patient is male and whether he is over 18.  Isn't that in his file already?  Don't you have his sex and date of birth?  I know you have his date of birth because you asked me for it three times and made me enter it into the phone.  The first time around, prior to starting therapy, we need to tell the plan whether the patient has had two low testosterone levels.  Why ask this again six months later.  Will his pre-therapy levels miraculously change? 

And patients on an insulin pump - Medicare will not cover supplies unless they receive proof that the patient has type 1 diabetes (in the form of antibodies against the insulin producing cells of the body) or that he does not make endogenous insulin (using a blood test called the C-peptide).  And they want this information annually.  Why?  Do they think his type 1 diabetes will go away? That his pancreas will recover and start making insulin?

In today's computer age, it must be simplified to forego some of the redundant questions that are part of obtaining approval for patients' drugs.  It makes me wonder if they do this just so physicians say "forget it" and give up.  I have no problem with using the older, generic, less expensive drugs when appropriate, but not uncommonly, newer medications are necessary.  And not for nothing, I've had to get prior authorizations for generic drugs, too.  Don't get me started on that.