What started as a simple tool to cut costs has exploded into a tangled mess of red tape – delaying care, wasting billions and leaving doctors and patients under piles of paperwork.
As someone who studies the system’s design, I’ll say it plainly: prior authorization was never about care — it was about control. What started as “cost containment” has metastasized into a tool for delay, denial, and deterrence. When even physicians with insider knowledge have to fight behind the scenes, what chance do regular patients have? This isn’t just inefficiency — it’s engineered exhaustion. Time to empty the drawer and start over.
As a patient, several of my medicines need prior authorization. I used to be in a yearly schedule where my doctor had to send in a prior authorization once a year. Last year, when it was time to send in the yearly prior authorization, I received only 3 months of approval. Since then, my doctor must send in a PA every 3 months.
I think they are hoping the extra paperwork will lead my doctor to prescribe a different, cheaper medicine.
Well written and thought-provoking. How do we get the right Congressional people focused on this and find a better solution than Prior Authorization as it exists today?
Ask all Senators and Representatives to co sponsor the reintroduction of Medicare For All act in this current 119th Congress. This bill cares for the whole body.
OMG! I have been trying to refill my rescue inhaler since Saturday. I stopped to pick it up Saturday and my coupon card had expired (so it would cost me $0). I came back Sunday, dropped off another coupon card, which the pharmacy was having trouble with on the website. We need to call the coupon company, but can't on the weekend, we'll call on Monday.
On Tuesday, I stopped to pickup it up but found out that the coupon card only works if my insurance "approves" the drug. They need to get a prior authorization from the prescribed.
After multiple messages to providers and multiple phone calls, the prior authorization has been completed and sent to insurance.
Of course, I have to wait for a LETTER from my insurance saying that this inhaler is covered.
Without insurance, my rescue inhaler costs ~$700! While talking to insurance they said the PA completed in December when I initially filled my prescription had been denied. The coupon card still paid for it (which has since changed). The reason it was denied: they didn't use my insurance companies PA form, they used one that I assume most pharmacies use. 🤪
In many cases it’s also used to speed up care once an initial auth is created, which should take a provider mere minutes.
Then, whenever that same medication or procedure code comes through again, it’s instantly processed.
This is where the cost savings comes from as care becomes more costly and less efficient every time someone has to touch a case, auth or a claim.
The payors that I work with have used the process in this fashion as part of a larger plan to increase auto-adjudication of claims, which also reduces costs.
When it comes to things like cancer, MSK, cardiology, radiology and other speciality testing, these are typically farmed out to a third party on a contractual basis.
HealthHelp and eviCore are examples of vendors that operate in that space.
So, I’m back to the same 2 points again.
1.) It must be understood that we are in an unprecedented time when it comes to the mass consumption of care because of the aging out of the boomers.
This will be the case for about another 9-10 years.
That’s why so many of these posts are always focused on Medicare, because they are written by boomers.
2.) Why do people incessantly go after the middle man (payors) instead of going after the providers and the exorbitant prices they charge? That’s the real problem.
Facilities are absolutely considered providers. That’s why they have NPI’s 🤦♂️
Why should my neurosurgery cost $250,000?
Why was the ER visit alone $15,000?
For a few X-rays, an MRI and a diagnosis?
This is my point when it comes to providers, which absolutely include facilities.
I’ll put the information below for you.
I’ve made the point about boomers a few times now.
It’s a massive bubble in the healthcare food chain that’s been predicted and known about for years and years.
The common thinking is that this should peak around 2035.
The other point I’ve made is that many of those boomer types who post here are spreading poor information for their own purposes, they don’t care about us at all.
The reality is we need future looking solutions that go beyond the current bubble. Failure to do so will enslave us all to a system that isn’t built to serve the population that will actually be here, but rather is built to serve the bubble.
Suggested read:
The Information Cure
( ISBN 978-1-60743-391-0 )
It was written about 15 years ago and is only 100+ pages or so.
Here’s your facility as a provider information.
In insurance terms, a provider is an individual or entity that delivers healthcare services or supplies to patients and is eligible to bill the insurance company for those services. This typically includes:
• Individual providers: Licensed healthcare professionals such as physicians, nurse practitioners, dentists, therapists, or chiropractors.
• Institutional providers: Organizations or facilities that provide healthcare services, such as hospitals, clinics, urgent care centers, nursing homes, or diagnostic labs.
Can a Facility Be a Provider?
Yes, a facility can absolutely be considered a provider in insurance terms. Institutional providers, like hospitals or outpatient surgery centers, are classified as providers because they deliver medical services and can submit claims to insurance companies for reimbursement.
For example:
• A hospital providing inpatient care or emergency services is an institutional provider.
• A diagnostic imaging center performing MRIs or X-rays is also a provider.
Key Points:
• Providers, whether individuals or facilities, must often be in-network (contracted with the insurance plan) or out-of-network (not contracted), which affects coverage and costs.
• Facilities are typically billed separately from individual providers. For instance, during a hospital visit, you might receive one bill from the hospital (facility provider) for room and equipment use and another from the attending physician (individual provider) for their services.
• In insurance claims, providers are identified by National Provider Identifier (NPI) numbers, which apply to both individuals and facilities.
Why you always dissing on boomers? Why you say we should go after exorbitant provider reimbursement instead of insurance corporations and other payors? Just to be contrary?
Have you never looked at your medical bills? Provider portion is always a tiny fraction of the total surgery bill.
Do you think paying your surgeon $395 for doing an appendectomy is too much?
Because it means a lot more than a simple fee for a surgeon.
Also, are you under the impression that payors set the prices for providers outside of capitation contracts, which actually bring prices down?
Finally, yes I have.
I had a $250,000 neurosurgery procedure 2 years ago when I shattered a vertebrae in my neck and it was discovered I had cervical stenosis impacting 4 others. 8 hour surgery and 8 days in the hospital.
So, yeah I know what it costs. I also know UHC paid the whole bill except for my max out of pocket.
Since you asked, here’s some info on appendectomy’s, which can vary wildly depending on a host of variables.
The cost of an appendectomy can vary widely based on factors like location, hospital type, surgeon’s experience, and whether the procedure is open or laparoscopic. Surgeon-specific fees are often bundled into the total cost, which includes hospital charges, anesthesia, and supplies, making it tricky to isolate the surgeon’s fee alone. Based on available data, here’s what we can piece together:
• Surgeon Fees: Studies and reports suggest individual surgeon costs for an appendectomy range from $197 to $1,181, depending on the procedure’s complexity and the surgeon’s expertise.
• Total Procedure Costs:
• In the U.S., the average total cost for an appendectomy is around $7,800 to $33,000, with extremes ranging from $1,500 to $180,000.
• Laparoscopic appendectomy costs typically fall between $7,035 and $13,853 for uninsured patients.
• In specific regions, like Pennsylvania, total cash costs start around $8,319.
• Internationally, costs are lower. In India, surgeon fees and hospital costs together range from ₹30,000 to ₹1,00,000 (~$360–$1,200 USD).
• A 2020 post on X cited an average U.S. appendectomy cost of $15,930, compared to $3,814 in the UK.
• Context: Costs are higher for ruptured appendices (up to $12,800 on average) and vary by facility type (e.g., private vs. public hospitals). Cash prices can sometimes be negotiated lower, especially with insurance like Sidecar Health, which may reduce costs by up to 40%.
Why the Range? Surgeon fees depend on their reputation, the procedure’s urgency, and regional pricing norms. Hospital markups and additional services (e.g., overnight stays) often dwarf the surgeon’s cut. For instance, a Reddit user reported a $48,750 bill for a laparoscopic appendectomy, though typical reimbursements are closer to $700, hinting at inflated hospital charges rather than surgeon fees.
Bottom Line: The surgeon’s fee for an appendectomy is likely $200–$1,200 in the U.S., but total costs often hit $7,000–$35,000 due to hospital and ancillary charges. For a precise estimate, you’d need to check with local surgeons or hospitals, as prices vary by state and facility. If you’re uninsured, platforms like MDsave.com can help find cash prices. If you share your location or insurance status, I can try to narrow it down further.
Let’s do some insurance vocabulary: a provider is a physician, nurse practitioner or physician assistant. A professional who bills under ICD10 diagnostic codes for office visits or procedures.
You’re mistakenly including hospitals and surgery centers in the term provider. These are distinct entities that bill patients and insurance directly for the hospital portion and the facilities charges for a procedure separately. They are the ones who bill exorbitantly, and drive up the price of healthcare in the US. This is where you see the variation in charges for identical procedures, inflated already by greed, allowed by statute to increase with inflation, and differing based on reputation. (MD Anderson Cancer Center can charge INSCOs more than a community hospital for the same procedure code).
These entities are able to negotiate with INSCOs and CMS based on the qualities you list. These entities may own physician practices, and can therefore tack on extra facility fees that independent physicians practices cannot. These do not flow to the providers who actually do the care.
I don’t know where you got the notion that physicians can negotiate with INSCOs based on their expertise, but that stopped ~2010. In independent physician practices, they tell US what we’re getting paid, “take it or leave it”, which is why you’ll find physicians with expertise don’t take certain plans ( aren’t “in network” for low paying plans), and newer physicians take everything until they build their practice and can discard the poorly paying plans.
Physician/Provider reimbursement is not tied to any measure of inflation, and is stated as a “percentage of Medicare” in our INSCO contracts. Today, a good “plan might reimburse 130% of Medicare fees, and a bad plan only reimburse 90% of the Medicare allowed charges. That’s what we mean when we say everything is “tied to Medicare”. Since provider reimbursement is not tied to inflation, and since it has not been increased in 25+ years, we have both an inflationary decrease in provider reimbursement and a capitalistic decrease in provider reimbursement over the same time frame that hospital reimbursement has increased dramatically. Example: global maternity care used to reimburse the OBGyn ~3800$ from first OB visit to 6 weeks postpartum (including delivery), now ~2800$ is about average, and “bad” plans pay as low as 1700$. This decrease is in the face of wildly increased costs of delivery for the patients- who may pay upwards of 15k to the hospital for a normal delivery.
Such a complicated calculus, designed by INSCO and hospital wonks colluding to obscure the inner workings of the American healthcare economy. The opposite of transparency, and a huge source of fraud, waste and abuse.
I have a feeling you and I agree on most things, but you come from a different point of view more sympathetic to INSCOs. Maybe work for a third party payor?
I still want to hear why you blame the boomers for our healthcare economy woes, and state that our problems will be solved once boomers die off in a decade. It should be interesting to hear you defend that statement.
As someone who studies the system’s design, I’ll say it plainly: prior authorization was never about care — it was about control. What started as “cost containment” has metastasized into a tool for delay, denial, and deterrence. When even physicians with insider knowledge have to fight behind the scenes, what chance do regular patients have? This isn’t just inefficiency — it’s engineered exhaustion. Time to empty the drawer and start over.
I agree that it is often a waste of time seeking preauthorization to see a specialist. These are hidden costs that delay timely care for patients.
As a patient, several of my medicines need prior authorization. I used to be in a yearly schedule where my doctor had to send in a prior authorization once a year. Last year, when it was time to send in the yearly prior authorization, I received only 3 months of approval. Since then, my doctor must send in a PA every 3 months.
I think they are hoping the extra paperwork will lead my doctor to prescribe a different, cheaper medicine.
Well written and thought-provoking. How do we get the right Congressional people focused on this and find a better solution than Prior Authorization as it exists today?
Ask all Senators and Representatives to co sponsor the reintroduction of Medicare For All act in this current 119th Congress. This bill cares for the whole body.
The goal is to kick the can down the road and for people to give up and go away, and die.
OMG! I have been trying to refill my rescue inhaler since Saturday. I stopped to pick it up Saturday and my coupon card had expired (so it would cost me $0). I came back Sunday, dropped off another coupon card, which the pharmacy was having trouble with on the website. We need to call the coupon company, but can't on the weekend, we'll call on Monday.
On Tuesday, I stopped to pickup it up but found out that the coupon card only works if my insurance "approves" the drug. They need to get a prior authorization from the prescribed.
After multiple messages to providers and multiple phone calls, the prior authorization has been completed and sent to insurance.
Of course, I have to wait for a LETTER from my insurance saying that this inhaler is covered.
Without insurance, my rescue inhaler costs ~$700! While talking to insurance they said the PA completed in December when I initially filled my prescription had been denied. The coupon card still paid for it (which has since changed). The reason it was denied: they didn't use my insurance companies PA form, they used one that I assume most pharmacies use. 🤪
I'm so tired of fighting for everything!!
This post doesn’t go far enough in explaining PA.
In many cases it’s also used to speed up care once an initial auth is created, which should take a provider mere minutes.
Then, whenever that same medication or procedure code comes through again, it’s instantly processed.
This is where the cost savings comes from as care becomes more costly and less efficient every time someone has to touch a case, auth or a claim.
The payors that I work with have used the process in this fashion as part of a larger plan to increase auto-adjudication of claims, which also reduces costs.
When it comes to things like cancer, MSK, cardiology, radiology and other speciality testing, these are typically farmed out to a third party on a contractual basis.
HealthHelp and eviCore are examples of vendors that operate in that space.
So, I’m back to the same 2 points again.
1.) It must be understood that we are in an unprecedented time when it comes to the mass consumption of care because of the aging out of the boomers.
This will be the case for about another 9-10 years.
That’s why so many of these posts are always focused on Medicare, because they are written by boomers.
2.) Why do people incessantly go after the middle man (payors) instead of going after the providers and the exorbitant prices they charge? That’s the real problem.
Wrong again my love.
Facilities are absolutely considered providers. That’s why they have NPI’s 🤦♂️
Why should my neurosurgery cost $250,000?
Why was the ER visit alone $15,000?
For a few X-rays, an MRI and a diagnosis?
This is my point when it comes to providers, which absolutely include facilities.
I’ll put the information below for you.
I’ve made the point about boomers a few times now.
It’s a massive bubble in the healthcare food chain that’s been predicted and known about for years and years.
The common thinking is that this should peak around 2035.
The other point I’ve made is that many of those boomer types who post here are spreading poor information for their own purposes, they don’t care about us at all.
The reality is we need future looking solutions that go beyond the current bubble. Failure to do so will enslave us all to a system that isn’t built to serve the population that will actually be here, but rather is built to serve the bubble.
Suggested read:
The Information Cure
( ISBN 978-1-60743-391-0 )
It was written about 15 years ago and is only 100+ pages or so.
Here’s your facility as a provider information.
In insurance terms, a provider is an individual or entity that delivers healthcare services or supplies to patients and is eligible to bill the insurance company for those services. This typically includes:
• Individual providers: Licensed healthcare professionals such as physicians, nurse practitioners, dentists, therapists, or chiropractors.
• Institutional providers: Organizations or facilities that provide healthcare services, such as hospitals, clinics, urgent care centers, nursing homes, or diagnostic labs.
Can a Facility Be a Provider?
Yes, a facility can absolutely be considered a provider in insurance terms. Institutional providers, like hospitals or outpatient surgery centers, are classified as providers because they deliver medical services and can submit claims to insurance companies for reimbursement.
For example:
• A hospital providing inpatient care or emergency services is an institutional provider.
• A diagnostic imaging center performing MRIs or X-rays is also a provider.
Key Points:
• Providers, whether individuals or facilities, must often be in-network (contracted with the insurance plan) or out-of-network (not contracted), which affects coverage and costs.
• Facilities are typically billed separately from individual providers. For instance, during a hospital visit, you might receive one bill from the hospital (facility provider) for room and equipment use and another from the attending physician (individual provider) for their services.
• In insurance claims, providers are identified by National Provider Identifier (NPI) numbers, which apply to both individuals and facilities.
Jerry. Your way of communicating is so contrary.
Why you always dissing on boomers? Why you say we should go after exorbitant provider reimbursement instead of insurance corporations and other payors? Just to be contrary?
Have you never looked at your medical bills? Provider portion is always a tiny fraction of the total surgery bill.
Do you think paying your surgeon $395 for doing an appendectomy is too much?
What do you think “provider” means?
Because it means a lot more than a simple fee for a surgeon.
Also, are you under the impression that payors set the prices for providers outside of capitation contracts, which actually bring prices down?
Finally, yes I have.
I had a $250,000 neurosurgery procedure 2 years ago when I shattered a vertebrae in my neck and it was discovered I had cervical stenosis impacting 4 others. 8 hour surgery and 8 days in the hospital.
So, yeah I know what it costs. I also know UHC paid the whole bill except for my max out of pocket.
Since you asked, here’s some info on appendectomy’s, which can vary wildly depending on a host of variables.
The cost of an appendectomy can vary widely based on factors like location, hospital type, surgeon’s experience, and whether the procedure is open or laparoscopic. Surgeon-specific fees are often bundled into the total cost, which includes hospital charges, anesthesia, and supplies, making it tricky to isolate the surgeon’s fee alone. Based on available data, here’s what we can piece together:
• Surgeon Fees: Studies and reports suggest individual surgeon costs for an appendectomy range from $197 to $1,181, depending on the procedure’s complexity and the surgeon’s expertise.
• Total Procedure Costs:
• In the U.S., the average total cost for an appendectomy is around $7,800 to $33,000, with extremes ranging from $1,500 to $180,000.
• Laparoscopic appendectomy costs typically fall between $7,035 and $13,853 for uninsured patients.
• In specific regions, like Pennsylvania, total cash costs start around $8,319.
• Internationally, costs are lower. In India, surgeon fees and hospital costs together range from ₹30,000 to ₹1,00,000 (~$360–$1,200 USD).
• A 2020 post on X cited an average U.S. appendectomy cost of $15,930, compared to $3,814 in the UK.
• Context: Costs are higher for ruptured appendices (up to $12,800 on average) and vary by facility type (e.g., private vs. public hospitals). Cash prices can sometimes be negotiated lower, especially with insurance like Sidecar Health, which may reduce costs by up to 40%.
Why the Range? Surgeon fees depend on their reputation, the procedure’s urgency, and regional pricing norms. Hospital markups and additional services (e.g., overnight stays) often dwarf the surgeon’s cut. For instance, a Reddit user reported a $48,750 bill for a laparoscopic appendectomy, though typical reimbursements are closer to $700, hinting at inflated hospital charges rather than surgeon fees.
Bottom Line: The surgeon’s fee for an appendectomy is likely $200–$1,200 in the U.S., but total costs often hit $7,000–$35,000 due to hospital and ancillary charges. For a precise estimate, you’d need to check with local surgeons or hospitals, as prices vary by state and facility. If you’re uninsured, platforms like MDsave.com can help find cash prices. If you share your location or insurance status, I can try to narrow it down further.
Jerry, Jerry
Let’s do some insurance vocabulary: a provider is a physician, nurse practitioner or physician assistant. A professional who bills under ICD10 diagnostic codes for office visits or procedures.
You’re mistakenly including hospitals and surgery centers in the term provider. These are distinct entities that bill patients and insurance directly for the hospital portion and the facilities charges for a procedure separately. They are the ones who bill exorbitantly, and drive up the price of healthcare in the US. This is where you see the variation in charges for identical procedures, inflated already by greed, allowed by statute to increase with inflation, and differing based on reputation. (MD Anderson Cancer Center can charge INSCOs more than a community hospital for the same procedure code).
These entities are able to negotiate with INSCOs and CMS based on the qualities you list. These entities may own physician practices, and can therefore tack on extra facility fees that independent physicians practices cannot. These do not flow to the providers who actually do the care.
I don’t know where you got the notion that physicians can negotiate with INSCOs based on their expertise, but that stopped ~2010. In independent physician practices, they tell US what we’re getting paid, “take it or leave it”, which is why you’ll find physicians with expertise don’t take certain plans ( aren’t “in network” for low paying plans), and newer physicians take everything until they build their practice and can discard the poorly paying plans.
Physician/Provider reimbursement is not tied to any measure of inflation, and is stated as a “percentage of Medicare” in our INSCO contracts. Today, a good “plan might reimburse 130% of Medicare fees, and a bad plan only reimburse 90% of the Medicare allowed charges. That’s what we mean when we say everything is “tied to Medicare”. Since provider reimbursement is not tied to inflation, and since it has not been increased in 25+ years, we have both an inflationary decrease in provider reimbursement and a capitalistic decrease in provider reimbursement over the same time frame that hospital reimbursement has increased dramatically. Example: global maternity care used to reimburse the OBGyn ~3800$ from first OB visit to 6 weeks postpartum (including delivery), now ~2800$ is about average, and “bad” plans pay as low as 1700$. This decrease is in the face of wildly increased costs of delivery for the patients- who may pay upwards of 15k to the hospital for a normal delivery.
Such a complicated calculus, designed by INSCO and hospital wonks colluding to obscure the inner workings of the American healthcare economy. The opposite of transparency, and a huge source of fraud, waste and abuse.
I have a feeling you and I agree on most things, but you come from a different point of view more sympathetic to INSCOs. Maybe work for a third party payor?
I still want to hear why you blame the boomers for our healthcare economy woes, and state that our problems will be solved once boomers die off in a decade. It should be interesting to hear you defend that statement.