Prior authorizations are a joke.
The idea behind them, at least on paper, sounds reasonable. Insurance companies say they want to prevent unnecessary care, control costs, and ensure patients receive treatments that are “medically necessary.” In theory, that sounds responsible. In reality, the way prior authorizations are implemented turns that concept into something bordering on absurd.
What actually happens is that a health insurance company tells the medical expert in their network—the physician who is seeing the patient—that a particular treatment is “not medically necessary.”
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Let’s pause for a moment and appreciate how strange that is.
You have a physician who spent years in medical school, years in residency, and possibly additional time in fellowship training. That physician has examined the patient, taken a history, reviewed imaging, performed a physical exam, and developed a treatment plan based on professional judgment.
Then someone at the insurance company, who has never met the patient, never examined them, and often has not even spoken to them, decides that the treatment is unnecessary.
How exactly would they know?
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Medicine is not practiced through spreadsheets and billing codes. It requires context, judgment, and direct interaction with patients. Two patients with the same diagnosis code can present with very different clinical pictures. One may require aggressive treatment while another may do well with conservative care.
That is why physicians examine patients.
If I tried to make medical decisions about someone I had never evaluated, never spoken with, and barely reviewed records on, I could risk losing my medical license. Physicians are expected to base decisions on real clinical evaluation. If we do not, we are held accountable.
Yet this standard does not apply to health insurance companies.
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Insurers routinely deny treatments based on internal criteria that are often opaque and inconsistent. The decision is usually made by someone who has never seen the patient. Sometimes it is another physician working for the insurer. Sometimes it is not a physician at all.
Regardless, the result is the same. A medical decision is made without a medical evaluation.
Even when there is a “peer-to-peer” review, the process can feel more like a bureaucratic ritual than a meaningful clinical discussion. A physician spends time on the phone explaining why a patient needs a treatment that was already determined to be appropriate. Meanwhile, the patient waits.
They wait for care.
They wait for relief.
They wait for someone at an insurance company to approve something their doctor has already determined is necessary.
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All of this adds friction and delay to the healthcare system. Physicians and their staff spend enormous amounts of time completing forms, submitting documentation, and disputing insurance decisions over treatments that should have been straightforward.
Those hours come from the same limited pool of time that could have been spent seeing patients.
Perhaps the most remarkable part of this system is the absence of accountability.
When a physician makes a medical decision, we carry medical liability for that choice. If we make the wrong call, legal consequences may follow. That is part of practicing medicine. Responsibility and liability go together.
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Insurance companies, however, influence medical care every day through the prior authorization process. They determine which treatments move forward and which do not. Their decisions can delay care, alter treatment plans, or prevent patients from receiving recommended therapies.
Yet they carry almost none of the medical liability associated with those choices.
That imbalance is difficult to justify.
If an insurance company overrides the treating physician and declares that a treatment is “not medically necessary,” it is effectively making a medical decision. And if it is making medical decisions, it should be subject to the same standards of accountability as the rest of the medical profession.
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In other words, insurers should carry medical liability for their denials.
If a denial leads to harm because a patient did not receive the care their physician recommended, the entity that blocked the treatment should share responsibility. That is how accountability works throughout medicine.
Right now, the system allows insurance companies to influence medical care while avoiding the risks tied to those decisions.
It is easy to deny care when there is no downside.
If insurers had to stand behind their determinations the way physicians do, if they assumed real medical liability for denying treatment, the prior authorization landscape might look very different.
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Criteria might become more reasonable. Denials might become less reflexive. Medical judgment might once again rest primarily with the physicians who actually evaluate patients.
Until then, prior authorizations will continue to feel less like a safeguard for patients and more like what many physicians already recognize them to be.
A bureaucratic obstacle placed between doctors and the care they are trying to provide.
If insurance companies are confident enough to overrule physicians, then perhaps it is time for them to do what the rest of us in medicine must do.
Put their money where their mouth is.
If I tried to make medical decisions about someone I had never evaluated, never spoken with, and barely reviewed records on, I could risk losing my medical license.
