Caregiver Experiences of Managing Insurance Prior Authorization: Results from a Survey Study

Background and Purpose: Prior authorization (PA) is the process of obtaining pre-approval from a payor for services, procedures, and medications to ensure financial coverage. Previous research on the effects of PA has examined provider or patient views, but little is known about the assistance that informal caregivers (family members and friends) provide patients in navigating the health insurance system. To examine the social context of PA, we assessed respondents’ involvement in dealing with PA for a friend or family member’s care. We explored correlates of dealing with PA for a friend or family member, characterized individuals’ PA experiences, and examined self-reported outcomes of PA.

Methods: PA items were assessed via a survey administered through the Qualtrics Online Panel Platform to a convenience sample of U.S. adults (≥18 years) December 2024-January 2025. Participants self-reported information about demographics, health information, and PA experiences. Participants were asked, “In the past year, have you dealt with prior authorization for a family member or friend’s healthcare?” Those responding yes were asked about their most recent experiences with PA: who needed the PA, what treatment or services the PA was for, how the respondent was notified about the PA, their involvement in the PA process, outcome of the PA, delays in care resulting from the PA, and perceptions of PA-related burden. Correlates of dealing with PA for a friend/family member and PA outcomes were examined using unadjusted and adjusted logistic regression models conducted in SAS Version 9.4.

Results: Of 993 survey respondents, 18% (182) reported dealing with PA for a friend or family member, most commonly a partner/spouse (32%), child (22%), or parent (19%). The most common treatment/service requiring PA was medication (40%). Respondents most often found out PA was needed via notification from the healthcare team (45%). 82% of caregivers reported being actively involved in the PA process (e.g., by contacting the healthcare team or pharmacy). Just under one-half (48%) reported the patient’s treatment or service was approved by insurance and the patient received the recommended care. Thirty-eight percent of caregivers reported dealing with PA was a moderate or serious problem. In the full sample, participants who were younger, working full- or part-time, and identified as a race/ethnicity other than non-Hispanic white were more likely to report dealing with PA for another person. Caregiver involvement in the PA process was associated with lower odds of having the care approved and having the patient receive recommended care (aOR = 0.20, 95% CI [0.08-0.53]) and greater odds of reporting PA was a moderate/serious problem (aOR = 3.06, 95% CI [1.16-8.09]) and reporting a delay in the patient’s care (aOR = 2.91, 95% CI [1.20-7.06]).

Conclusions and Implications: This study is one of the first to examine caregivers’ experiences dealing with PA. Our findings suggest that PA imposes burdens beyond those experienced by patients and healthcare teams. Future work should link survey and electronic health record data; use qualitative methods to explore caregivers’ PA involvement; and develop multilevel interventions to enable social workers to support patients and families.