Prior authorization could stand between you and your doctor’s care and here's what it really means, how delays happen and what do if you’re denied

For many, it’s one of the most challenging parts of the U.S. health care maze: prior authorization. It’s the insurance red tape that requires your doctor to get approval before you receive certain treatments, tests or medications (1).

In theory, it’s supposed to keep costs in check and make sure care is actually needed. But in reality, it can often mean delays, denials, and endless frustration when paperwork stands between patients and the care they need.

A painful waiting game

If you’ve ever waited days, weeks or months for your doctor to get the green light from your insurance company before moving forward with treatment, you’ve likely felt the sting of priorization. And according to a recent New York Times report, this red-tape ritual is becoming a serious pain point for both doctors and patients (2).

The idea behind it seems reasonable: Insurers want to ensure treatments are medically necessary before they pay for them. But in practice, it often means delayed appointments, stalled medication refills or postponed surgeries. For patients with chronic or urgent conditions, those delays can make things worse.

The American Medical Association (AMA) warns that the wait for approval complicates life for everyone involved (3). Missed therapy windows or surgery delays can add stress, worsen symptoms and push patients into costly care they didn’t need in the first place.

Denials only add to the problem. In 2023, Medicare Advantage insurers received nearly 50 million prior authorization requests, according to the Kaiser Family Foundation (4). About 6.4% were denied in full or in part, amounting to roughly 3.2 million decisions that blocked or restricted care. Rates varied widely, with Humana denying just 3.5% and Centene rejecting about 13.6%.

Common reasons for denial include:

• A clerical error, like a typo or wrong billing code
• Missing or unclear documentation
• A treatment that isn’t covered under the plan
• Care at a hospital that’s not within the policy’s network

Whether those denials are partial or full, the outcome is the same: Patients wait longer or pay out of pocket.

The power of the appeal

Waiting for medical approval is stressful enough, but the financial hit can be just as painful.

Take knee replacement surgery, for example. It’s one of the most common orthopedic procedures in the country, according to CareCredit, and can cost anywhere from $14,000 to about $49,000, depending on the hospital and care required (5). If your insurer refuses to approve it, you could be stuck footing the bill.

But don’t lose hope. The AMA says that over 80% of prior authorization appeals succeed, and you don’t have to go it alone (6).

Doctors often have better success with appeals because they know what insurers look for and how to provide the right medical evidence. If you have employer-based insurance, your HR department can also step in to help review forms, resolve errors and push the case forward.