GET WHAT YOU'RE OWED FROM YOUR HEALTH INSURANCE PLAN

If your insurer refuses to pay for a treatment or procedure that you believe should be covered, use our guide to appeal.

- BY KIMBERLY LANKFORD

Depending on your health insurance policy, you may have noticed that you need to get permission from your insurer before it will pay for a medication, treatment or procedure your doctor prescribes—even if it’s covered by your plan. This extra step, called prior authorization, is becoming more common with most types of health insurance, including Medicare Advantage, employer coverage, and individual plans sold through HealthCare.gov or your state health insurance marketplace. When your health plan requires prior authorization, your doctor must provide evidence that the specific care is medically necessary and is the best course of action in your situation.

Prior-authorization requirements have increased significantly over the past few years. For example, virtually all enrollees in Medicare Advantage plans are required to obtain prior authorization for some services, and these insurers made nearly 50 million prior-authorization determinations in 2023, up from 37 million in 2021, according to health policy research organization KFF.

Insurers don't always approve these requests. In 2023, for example, Medicare Advantage insurers fully or partially denied 3.2 million prior authorization requests, according to KFF. Insurers say that prior authorization provides a vital screen to ensure patients receive safe, evidence-based care and to reduce low-value and inappropriate services so that coverage is as affordable as possible.

The American Medical Association, however, calls prior authorization "an overused process that interferes with patients receiving timely care, or even any care at all." More than one in four physicians report that delays or denials related to prior authorization have led to a serious adverse event, such as hospitalization, disability or even death for a patient in their care.

And prior authorization isn't the only obstacle you may encounter.