The Future of Healthcare: Virtualization Ahead

Advocating for Change: Enhancing Patient Rights in the Prior Authorization Procedure

Unlock the power of patient rights in the prior authorization procedure. Dive deeper to learn how you can advocate for better care today.

Video Thumbnail

Delving into the intricacies of healthcare coverage, a common query arises: does medicare require prior authorization? This question is pivotal for patients and providers alike, influencing the accessibility and timeliness of medical services. As individuals navigate the complexities of Medicare, understanding the necessity of prior authorization can significantly impact their healthcare journey.

Let’s explore now!

Table of Contents

Advocating for Change: Enhancing Patient Rights in the Prior Authorization Procedure

patient rights in the prior authorization procedure with nursesPhysicians and patients have long been frustrated with the prior authorization (PA) process. The lengthy and frequently extremely complicated procedures that physicians must go through in order to have a treatment plan authorized cause delays in patient care. While the initial goals of PA, which were to control costs and guarantee optimal care, are commendable, the way the procedure currently operates frequently obstructs prompt treatment and shatters the patient-physician bond. We examine the existing PA process’s drawbacks in this blog post and suggest some improved patient rights that might result in a more patient-centric strategy.

The Current Conundrum of Prior Authorization

Despite the advancements in healthcare, the PA process has evolved at a different pace. It is often fraught with administrative burdens, with seemingly arbitrary denials leading to inevitable appeals. Physicians frequently report that the time and resources they dedicate to securing PAs detract from their ability to deliver care and can lead to burnout. On the other hand, patients often bear the brunt of delayed or unfulfilled treatment, which can significantly impact their health outcomes.

The critique of PA isn’t just anecdotal; it has concrete implications for the healthcare system. One study found that 40% of PAs are associated with a change in planned care and that one in five patients requiring PA did not receive the prescribed medication. This is a significant departure from the intended goal of PA, which was to prevent unnecessary treatments that could lead to overprescription and inflated healthcare costs.

Proposed Patient Rights in PA

It’s time to weigh the scale back toward what truly matters in healthcare – the patient. Here are several proposed patient rights that can help to address the shortcomings of the PA process:

Timely Access to and Treatments

Patients should immediately have a prior authorization decision. Studies indicate that these waits can lead to increased emergency department visits and hospitalizations, which not only disrupt the patient’s life but also add to the overall cost of healthcare.

Transparent Communication and Education

The PA process must become more transparent. Patients should be informed about it when a medication or treatment requires PA. This includes information about why the PA is necessary, what the approval process looks like, and what to expect regarding the timing of a decision.

Efficient and Streamlined Appeal Process

Patients should have access to a simple and efficient appeal process if a PA request is denied. This could involve clear guidance on how to appeal, the expected time for a decision on the appeal, and the option to speak with a healthcare provider or specialist during the appeals process.

Right to an Explanation of Denial

patient rights in the prior authorization procedure female doctor

Patients have a right to understand why their PA request was denied. This right extends to a detailed reason that can be easily understood, including whether the denial was based on medical necessity, coverage under the patient’s insurance, or other factors.

Option for Consecutive Prescriptions

In cases where prior authorization is initially denied, patients should have the option to receive a limited supply of the prescribed medication or treatment to cover them until the process is completed. This consecutive PA process ensures that care is not delayed while making a decision.

Strict Guidelines for Non-Medical Switching

Insurers and PBMs should be prohibited from conducting “non-medical switches” of patients from one covered drug to another during a policy year or treatment plan. These switches, often made due to formulary changes, can disrupt a patient’s treatment plan and waste the resources already allocated to the initial PA process.

What Our Clients Say About Us!
Victoria Nutting D.O.

I'm very thankful for Portiva who I know is looking after my practice while I'm gone the virtual assistants can manage prescription refills, documents they can triage patients and just kind of answer administrative questions and they can handle a lot on their own. But also, they're very good about contacting me if there's any emergency or anything I need to attend to. So I'm very thankful for Portiva they can help almost any provider almost anywhere and it really allows for some good work-life balance as I'm getting to experience right now at my family farm so I'm very thankful for Portiva and I'm very happy to use their services"

victoria nutting do
Victoria Nutting D.O.

Board Certified Family Medicine Physician

100 satisfaction
Mohammad Ashori, M.D.

Portiva's Virtual Medical Assistant - I have all the support I need. There's somebody checking my email, any patient messages. Patients are still able to schedule and handle any scheduling issues and any kind of billing that needs to still go through. Portiva hands handles it all for me. I have support i have somebody that I can access 24/7 pretty much. It's all very seamless. If somebody has an emergency or needs a medication called in. I know that the va's at portiva will handle that for me.

mohammad ashori md
Mohammad Ashori, M.D.

Board Certified Family Medicine Physician

100 satisfaction

Getting Through the Obstacles Ahead

patient rights in the prior authorization procedure with patientsIn order to implement these patient rights, the power dynamics in the healthcare system would inevitably change, giving patients and their caregivers a bigger say in how decisions are made. This change has included potential resistance from payers and PBMs, who might view it as an added administrative burden.

However, with suitable regulatory and incentive structures, these changes could lead to a more efficient and patient-friendly PA process. By nurturing a healthcare system based on trust, education, and clear communication, we can align the PA process with the true goal of all involved – the well-being of patients. The road to reforming the PA process is long, but with collaboration between physicians, patient advocates, legislators, and insurers, it is a path we can traverse. What’s needed now is continued dialogue and action to turn these proposed patient rights into standard practice. By doing so, we can ensure that the patient’s voice is heard and actively shape their healthcare future.

In advocating for change, we can create a system where patients feel heard and valued – a system that supports their well-being rather than creating barriers to it. The shift to enhanced patient rights in the PA process is a step toward building a more equitable and compassionate healthcare landscape. It’s a step we can all take together. So, let’s start the conversation and work towards a future where patients no longer have to navigate burdensome administrative processes to receive the care they need. Together, we can make a difference and prioritize the well-being of patients above all else. Let’s continue this journey towards patient-centric healthcare, one step at a time.


The PA process has significant implications for patients, physicians, and the healthcare system. By recognizing and addressing its flaws, we can advocate for patient rights that prioritize timely access to medications and treatments, transparent communication and education, efficient appeal processes, explanations for denials, options for consecutive prescriptions, and strict guidelines against non-medical switching. Even if there might be difficulties in putting these reforms into practice, we must keep working together to create a healthcare system that puts patients’ needs first. We can build a more just and compassionate healthcare system that benefits all patients by speaking up for their rights and continuing the conversation and taking action. It’s time to prioritize the patient over everything else in their care, even the PA procedure. Thus, let’s continue the discussion and strive toward a time when people can access the care they require without needless obstacles. We have the power to change things and provide everyone a better future in healthcare.

To learn more about healthcare that can enhance your medical practice. Discover more about Portiva and unlock a world of possibilities by visiting our homepage today!

Get Free Consultation
Our Top Virtual Assistants
Need Help?
Reach To Us Today!
Please Share This Post!