What is prior authorization and how could it impact my loved one’s care? 

Ashley Sumrall, chair-elect of the American Society of Clinical Oncology Government Relations Committee

When an oncologist or another physician requests certain treatments, procedures or tests, your loved one’s insurance company—whether it’s private health insurance or Medicare—will require additional information from the ordering physician. The insurer then uses that information to decide whether to cover or deny the treatment or test. This process is known as prior authorization or pre-authorization. Prior authorization comes up frequently, most often when a cancer treatment or test is expensive or when treatment is complex. It may also arise if your loved one is prescribed a new treatment that your insurance has not yet included in its formulary, which is a list of prescription drugs covered by an insurance plan.

While health insurers say this process ensures high-quality care and cost-effective treatment, prior authorization can be time-consuming for physicians and cancer clinics. It also can delay your loved one’s treatment or prevent them from accessing certain treatments, scans or procedures. If the requested treatment is denied, your loved one may incur increased costs or be forced to select a less preferable treatment option.

If the insurance company rejects the initial prior authorization request, your loved one’s physician will need to reach out to the insurer and have what’s called a “peer-to-peer” review. In this process, the ordering physician will contact a physician who works for the insurer to explain why the desired treatment or test is necessary and should be covered. These decisions ultimately are based on the insurer’s internal guidelines, which may differ from the guidelines an oncologist uses to make treatment decisions. In my own experience as an oncologist, once I’ve explained my rationale in a peer-to-peer review, we often get approval. However, even in this best-case scenario, the process will delay treatment.

While there is little you or your loved one can do to speed up or assist in this process, ask your insurance company about its procedures, which vary among insurers. Understanding how the system works may help alleviate feelings of uncertainty, confusion or frustration. Remember that your oncologist wants what is best for your loved one, but their hands will be tied if the insurer ultimately denies the request. If you find yourself in this position, ask your oncologist and health insurer about filing an appeal. Also ask your oncologist whether the drug company offers a patient assistance program that you can apply for to potentially receive the drug at no cost. Talk with your oncologist about alternative treatment options if your loved one needs a backup plan.

If prior authorization causes delays or barriers to your loved one’s treatment, reach out to your local representatives and lawmakers. Policymakers want to hear your stories, and this is a topic that deserves more attention.

Understanding Insurance // Cancer Support Community explains what you should know about prior authorization and how it can affect you. // The American Cancer Society offers advice on what to do when your insurer denies a treatment.

The expert’s response was edited for clarity and based on an interview with Kendall K. Morgan.