Prior authorization buries doctors in paperwork and delays care to patients, sometimes with disastrous results.
ByAfter experiencing mysterious hip and back pain for about six months, Dan Hurley finally went to see an orthopedist in December 2021. The diagnosis, after an MRI and a subsequent biopsy, was metastatic dedifferentiated chondrosarcoma, an aggressive cancer in his pelvic bone. Hurley, then 48, set about finding specialists who could maximize his chances of survival and grant him more time with his wife and three kids at their home in Phoenix.
It didn’t take long for Hurley’s concerns about prior-authorization delays to be proven correct. By July of last year, his tumor had proven so aggressive that doctors began to plot a new course of treatment. When they ordered a PET scan to assess the cancer in his body, Blue Cross denied it, prompting Hurley and his doctors to appeal the decision.
In the 1960s, hospitals began conducting reviews to determine the most cost-effective course of treatment for patients, and eventually, insurers developed their own standards to ensure consistency and regulate costs. As the prior-authorization system began to emerge, insurers typically only applied it to expensive types of care such as certain cancer treatments or cutting-edge medications.
In extreme cases, those patients don’t make it. In December 2007, Cigna found itself in the midst of a PR crisis after it denied prior authorization to Nataline Sarkisyan, a 17-year-old in Glendale, California, with recurrent leukemia who was in need of a liver transplant. Sarkisyan’s doctors pleaded her case, but Cigna held firm in its refusal, deeming the procedure “experimental.
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