Prior authorization is exactly that. It is the requirement that a health plan must approve the plan of care, prescription or therapy that a treating physician deems to be medically necessary and clinically appropriate before that care is delivered to the patient.

As health plans seek to control costs, utilization management practices including prior authorization are used. This places a middleman at a health plan in the center of medical treatment decision making for the primary purpose of containing costs. A health plan administrator who has never seen the patient is empowered to act as a gatekeeper to treatment and care. The prior authorization middleman interrupts direct patient care. Prior authorization paperwork requirements divert the time and attention of physicians, nurses and clinical staff from direct patient care. Prior authorization also interferes with medical decision-making — the foundation of the physician-patient relationship.

P+P United is committed to preventing 3rd party interference with patient care and preserving personalized treatment.

• Delays Treatment – Research funded by the National Institutes of Health found nearly “three-quarters (72.3%) of oral anticancer drug prescriptions required a prior authorization.” A closer look by that research at how prior authorization impacted patient care revealed “a quarter of patients (25%) waiting more than 14 days for their medication.” Delays are not a desired or beneficial element in any plan-of-care. Delays result in disease progression.
• Discredits Physician Expertise – Physicians lean heavily on their medical expertise and years of training when treating patients. An administrative middleman at a health plan who has never actually placed hands on the patient, evaluated lab and imaging test results, or studied a patient’s unique medical history does not know best the course of treatment for a patient.
• Threatens Personalized Medicine – Obstructing access to therapies interferes with the personalized treatment plans that physicians craft to meet the unique needs of each patient. A treatment that cannot reach patients due to health plan bureaucracy cannot improve a patient’s quality of life or medical condition.

• Paperwork or Patient Work? – Some forms of prior authorization require use of paper forms that are faxed from a physician office to a health plan. Each of these paper-based transactions takes a physician (or nurse, or practice manager or billing specialist) 21 minutes to complete. Those 21 minutes spent crisscrossing the utilization management administrative labyrinth could otherwise be spent on direct patient care, or by a nurse connecting with a concerned caregiver calling about a loved one’s symptoms, or by a practice manager scheduling an appointment for an overwhelmed patient that just received an alarming diagnosis.