Prior authorization (PA) is a requirement imposed by a patient’s health insurance carrier or pharmacy benefit manager (PBM) that mandates approval before covering specific medications, procedures, or medical services. This process ensures the insurer reviews the proposed treatment to verify it is medically necessary, evidence-based, and cost-effective before the patient receives care. When a doctor prescribes a treatment and then refuses to submit the necessary prior authorization paperwork, it creates an immediate barrier to care. Understanding the reasons for this refusal and the subsequent steps available can help patients navigate this complex challenge.
Common Reasons Why Providers Refuse
A primary reason for a physician’s refusal to engage with the prior authorization process is the immense administrative burden it places on their practice. Submitting a PA request is not a standardized, automated procedure; it frequently involves administrative staff manually reviewing payer-specific rules. This often requires hours of staff time dedicated to gathering clinical notes, filling out lengthy forms, and engaging in time-consuming communication with the insurance company.
Practices also face financial disincentives, as the substantial time and resources spent on completing PA paperwork are rarely reimbursed by insurance payers. This unpaid workload diverts staff from other patient-facing tasks and negatively impacts the overall efficiency of the medical practice. Some physicians may also refuse PA submission as a form of protest against a system they view as an inappropriate intrusion on their clinical judgment.
A different scenario involves a legitimate clinical disagreement. The physician may have initially considered the treatment but, upon further review, determined an alternative, less expensive therapy would be sufficient or that the prescribed treatment is not truly necessary. The refusal to submit the PA in this case stems from the doctor’s conviction that the treatment does not meet the necessary criteria.
The Legal and Contractual Role of Prior Authorization
The question of whether a doctor must submit a prior authorization is complex, resting on the distinction between ethical obligations and contractual agreements. While physicians have an ethical duty to facilitate medically necessary treatment, there is generally no direct law requiring them to complete every prior authorization form a patient requests. The requirement to submit PA usually stems from the individual contract the provider holds with the insurance plan, which outlines the terms for reimbursement.
These payer contracts often mandate that in-network providers cooperate with the insurer’s utilization management protocols, including prior authorization, to ensure payment for covered services. However, a provider’s refusal to submit a PA is rarely a direct violation of patient law, unless the refusal leads to patient abandonment or gross negligence regarding the standard of care. Patient abandonment occurs when a physician terminates a relationship without reasonable notice or without providing an opportunity for the patient to secure comparable care.
Some state laws are beginning to address the PA burden by requiring insurers to respond within specific timeframes or by establishing “gold card” programs that exempt providers with high approval rates from the process. Outside of these specific state mandates, the provider’s primary obligation is typically to facilitate care within the bounds of their professional and contractual duties.
Navigating the Process with Your Insurance Carrier
When a provider refuses to submit a prior authorization, the most productive immediate step is to contact the insurance carrier directly through the member services line. Patients should explain that their physician has prescribed a treatment but is declining the PA submission, putting the burden of advocacy on the payer. The insurer may have internal procedures that allow them to intervene or initiate the process themselves if the treatment is clearly covered under the patient’s plan.
The patient can ask the insurance company if they allow the member to self-initiate the prior authorization request, which shifts the administrative work to the insurer’s side. If self-initiation is permitted, the insurer will then typically contact the provider’s office to obtain the necessary clinical documentation, such as medical records and test results, to justify the medical necessity. Alternatively, the patient can request that the insurer contact the provider directly to explain the contractual obligation of the in-network physician to cooperate with the PA process.
If the relationship with the current physician is broken, the insurance carrier can provide a list of alternative in-network providers who routinely prescribe the same treatment and cooperate with prior authorization requirements. This action is often the quickest path to receiving the prescribed care without further delay.
Filing Complaints and Seeking Alternative Care
If the immediate steps with the insurance carrier fail to resolve the situation, formal avenues of recourse are available. Patients can file a formal grievance with the insurance company regarding the in-network provider’s refusal to follow utilization management procedures. This process creates a formal record of the breakdown in care and may prompt the insurer to take direct action against the provider for non-compliance with their contract.
A more serious action is filing a complaint with the state medical board, which regulates physician licensing and professional conduct. A complaint should focus on the physician’s failure to meet the standard of care or potential patient abandonment, rather than simply refusing paperwork. These boards investigate whether the refusal to submit a PA for a medically necessary treatment constitutes a breach of the physician’s professional obligations.
However, the fastest and most effective solution is often seeking a second opinion and transferring care to a new physician who is willing to submit the prior authorization. Switching providers avoids the lengthy bureaucratic process of formal complaints and immediately moves the patient toward receiving the prescribed treatment. Patients should request their medical records from the refusing doctor’s office, which is a right under law, to ensure a smooth transition to the new care team.