; Skip to Main Content
Skip Nav Destination

Prior Authorization

February 24, 2022

Blog: Family Connections with Pediatrics

If you have a child for whom a doctor ordered a special test, medicine, or equipment, then you have probably been through a process often required by health insurers called “prior authorization” to approve the order ahead of time.

While you may not have had your hand in all aspects of the process, you know that it has many steps, many forms, waiting, waiting, and waiting. All that waiting likely made you wonder, why is there such a delay?

Although you may not have proof that this delay affected the care and health of your child, you may have felt like it did - and you are not alone.

The “prior authorization” process is used by most insurance companies as a way to control costs, but it is unclear if the delays that come with this process have a negative effect on health.

This month in Pediatrics, the article, “Delays Related to Prior Authorization in Inflammatory Bowel Disease” by Constant et al set out to see if there are connections between prior authorization delays and the health of children with this specific disease (10.1542/peds.2021-052501). A related commentary, “Room to Improve Prior Authorization in Children with Complex Medical Needs” by Cook et al looks at delays in a broader way and suggests ways to improve the process (10.1542/peds.2021-054843).

What will you find in the “Delays Related to Prior Authorization in Inflammatory Bowel Disease” article?

The authors of this study looked back at children under 18 years diagnosed with Inflammatory Bowel Disease who started a certain type of new medicine between 2010 and 2020. They proposed that they would find that delayed start of the medicine caused increased health care use, such as hospitalizations and emergency room visits, in those children who required prior authorization and had to wait to get access to this medicine than those whose insurance did not require prior authorization.

The authors shared studies in adult rheumatology and asthma, and pediatric epilepsy that suggest that prior authorization may create delays that result in bad clinical outcomes. The article also cited a survey of physicians by the American Medical Association in which 94% reported that prior authorizations delay access to needed care, 90% perceived a negative impact on outcomes, and 30% reported that a prior authorization led to a serious adverse event for a patient in their care.

In the end, this study found that prior authorization delays were associated with poor outcomes and increased health care use. Even if your child does not have this specific disease or need this specific medicine, this is a key article that creates links between process delays to access a treatment and health outcomes, and presents concrete policy insights.

What will you learn about in the “Room to Improve Prior Authorization in Children with Complex Medical Needs” commentary?

The authors of this commentary describe current prior authorization reform efforts aimed to improve efficiency, transparency, and decrease variation of care delivered. Despite these efforts, the authors illustrate how difficult the process remains. Many doctors working with their office staff spend up to 16 hours weekly trying to get prior authorization approved for their patients.

This commentary also raises questions of equity. Using their own experiences with the effects of prior authorization delays on the care and health of complex, chronic patients, the authors ponder how children with more health needs are likely those with the highest share of prior authorizations needed to get important medicine, care, and equipment. Similar to the first article, these authors lay out concrete steps forward through strong partnerships among insurers, clinicians, patients, and families to design a much more efficient and standardized process to obtain prior authorization than the many different processes that different insurers may request before they approve a recommended treatment for a child. 

What can you do with these articles?

  1. Read and share these articles with your child’s doctors (pediatrician and specialists), therapists, pharmacists, supply or equipment company contacts etc. Share your concerns and ideas, and ask if they have thoughts.
  2. If you want to know what is or might be required, look into prior authorization processes with your child’s insurance. Do not be afraid to ask! You can do this on your own with a benefits information search on the website, portal, or call your child’s insurance. If there is a specific person who coordinates the process for your child’s doctor, provider, or supplier, ask them for information. Contact the Family-to-Family Health information Center in your state for assistance navigating health care financing information in your state. familyvoices.org/affiliates
  3. If you think that process delays, such as prior authorization, affect your child’s care or health, take notes or keep a journal. Keep track of things such as: whom you talk to, when forms were sent, dates, information asked for and sent, etc. Discuss your concerns with your child’s doctor or other provider related to that process.
Close Modal

or Create an Account

Close Modal
Close Modal