Life Kit

Health insurance hell: Why do I need a prior authorization?

February 10, 2026

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  • Prior authorizations are required by insurance companies to potentially prevent waste, fraud, and abuse, but the criteria for triggering them are often unclear, leading to frustration and delays for both patients and doctors. 
  • Patients must proactively track the expiration dates of ongoing prior authorizations by contacting their insurance company or pharmacy benefit manager, as communication regarding expiration can be opaque or easily missed. 
  • If care is delayed or a prior authorization is denied, patients can appeal the decision (which succeeds about half the time) or ask their doctor to request an urgent review to expedite the process, potentially down to 72 hours. 

Segments

Understanding Prior Authorization Triggers
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(00:00:26)
  • Key Takeaway: Prior authorizations are required before service to prevent unexpected patient bills and ensure medical necessity, though the specific triggers remain opaque.
  • Summary: When a doctor submits a claim post-procedure, insurance determines coverage, but prior authorization requires pre-approval. This process aims to protect patients from large bills and ensures insurance companies verify medical necessity beforehand. Doctors spend significant time on this paperwork, which can delay necessary care and worsen patient conditions.
Identifying Authorization Requirements
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(00:03:15)
  • Key Takeaway: Doctors generally know when authorizations are needed, but policies vary by insurer, and preemptive lists from insurance portals may not be fully up-to-date.
  • Summary: While doctors should have a sense of when prior authorization is needed, tracking the specific policies of different insurance companies is difficult. Patients might find partial lists on their insurance portals, but these lists can quickly become outdated as policies change throughout the year. Authorizations are often triggered by expensive treatments, but frustratingly, they can also apply to generic drugs and basic procedures.
Impact of Authorization Delays
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(00:04:43)
  • Key Takeaway: Physician surveys indicate that 90% report patient care delays due to authorization waits, and 80% see patients abandon recommended treatment because of these struggles.
  • Summary: Dr. David Azus noted that prior authorizations for cheap generic drugs are a frequent paperwork nightmare. Delays can lead to serious medical events, such as preventable vision loss for glaucoma patients. Furthermore, authorizations for ongoing treatment often require yearly renewal, sometimes catching patients off guard.
Patient Experience with Expiration
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(00:06:35)
  • Key Takeaway: Insurance companies should notify patients of prior authorization expiration, but communication is often opaque, leading to unexpected treatment disruption if not actively monitored.
  • Summary: Jacqueline Mayo experienced a disruption in her GLP-1 medication when her prior authorization expired after only seven months, causing physical stress. Experts note that communication regarding expiration is often opaque, appearing in fine print or complex language on denial letters. Patients dealing with health concerns may not be equipped to process this complex information effectively.
Actionable Steps for Patients
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(00:09:08)
  • Key Takeaway: Patients should proactively confirm authorization expiration dates, keep meticulous medical files for appeals, and request urgent review if waiting endangers health.
  • Summary: To prevent disruption, contact the entity handling your prior authorization (insurer or PBM) to determine expiration dates and read all correspondence carefully. If denied, appeal, as success rates are around 50% if new documentation or clarification is provided. If waiting puts health at risk, ask the doctor to submit an urgent review request, which often expedites the process to 72 hours.