Congress, end the "prior authorization" health-care scam

I recently had the good fortune to spend many hours on the phone with our family’s health insurance provider.

I know what you’re thinking: How can I do that too?

It’s easy. All you have to do is try to fill a basic medication prescribed by your doctor.

A few days ago, after more than three weeks of trying to get a very common drug approved by our insurer, my request was denied.

To find out why, can I simply log into the portal and read an explanation? Nope. Here in 2026, I must wait to receive a letter in the mail.

We’re not talking about some experimental, high-cost treatment. It’s a ubiquitous, cost-effective drug that has been approved for medical use for nearly four decades. It even has a generic, which I told the insurer I would gladly accept.

Alas, I don’t get to have it because of a long-running insurer scam known as “prior authorization.”

Here’s how it appears to work. Patients pay not-insignificant sums each month to a health insurance firm for doing, if all goes well, absolutely nothing. If the patients get insurance through work, their employers pay even more.

When one of these patients has the temerity to call upon the insurance company to do what it has been paid to do — say, fill a prescription from a licensed member of the medical community — he gets the runaround for days, weeks or even months. All the while, he is going without needed medical treatment.

Finally, he gets the news: He is just not allowed to have the prescription. The prior authorization team said so.

If he dares to wish to know why, well, he can just wait for his letter.

It’s a lucrative shakedown if you can get it, and insurers have been getting it since the passage of the 1973 Health Maintenance Organization Act.

Back then, prior authorization’s aim was the same ironic one of pretty much every other federal health care intervention: to cut costs. It applied only to expensive procedures or long hospital stays.

In the decades that followed, as enrollment in HMOs surged, so did the number of authorization requests. To handle them, every insurer created its own portal, each with different requirements. Physicians had to hire dedicated specialists just to wade through the forms. (Obamacare, unsurprisingly, made things worse.)

Today, the system is a fragmented, complicated mess, and insurers have no incentive to untangle it.

Denial of care equals profit. Most people don’t bother pursuing the matter when a prior authorization is denied, likely a testament to how time-consuming and difficult insurers make the whole process. Just 1 in 10 prior authorization requests denied in 2022 were appealed, according to a recent study by the health policy organization KFF.

“I always tell my patients now that when I write a prescription, I consider it a recommendation because I don’t know what’s going to be filled,” American Medical Association Chair David Aizuss said at a House hearing on health care affordability last month.

“We have to go through a prior authorization process frequently to get basic, long-standing generic drugs approved so that I can treat my patients’ glaucoma or whatever the problem may be.”

Prior authorization comes with a hefty price tag for doctors and patients. Physicians spend about $26.7 billion in time dealing with it, and patients spend about $35.8 billion, according to a 2021 paper published in Health Affairs.

The impact on patient health? In a New York State physicians survey, more than 40% of doctors said delays related to prior authorization had “led to serious adverse outcomes” for a patient, and almost 50% said such delays had resulted in a patient simply abandoning treatment.

The Doctor Knows Best Act would help stop this by “prohibit[ing] health insurance plans (including federal health care programs) from imposing a prior authorization requirement, utilization management technique (e.g., step therapy or fail-first protocol), or medical necessity review for any item or service for which benefits are available under the plan.”

Sucharu “Chris” Prakash wrote about “step therapy” in these pages last month. It’s a related practice in which insurers deny a prescription and force a patient “to try an older medication first,” even if it’s more likely to cause complications than the prescribed drug.

If the equivalent of prior authorization were happening in any other sector, we wouldn’t stand for it.

Imagine you put a dining room set on layaway at a furniture store and paid toward it every month. When you went to pick it up, you were told the store had decided that you should start with a children’s plastic picnic bench instead or, worse, that you shouldn’t get any furniture at all.

That retailer wouldn’t last five minutes in free-market America, nor should it. Yet we tolerate very similar behavior from insurance companies every day.

So, Congress, get your collective act together and stop letting insurers scam your constituents. Advance the Doctor Knows Best Act now.

• Anath Hartmann is deputy commentary editor for The Washington Times.