Prior Authorizations - Why Is My Medication or Test Being Delayed?

A Look Behind the Scenes at Prior Authorizations

If you’ve ever been told, “We’re just waiting on your insurance to approve it,” or “We need more information from your doctor,” then you have been trapped in a process called prior authorization (PA).

At Seeds of Health DPC, care should be clear, compassionate, and timely. But the reality of navigating insurance is that we often hit roadblocks—even when we know exactly what we need and why.

Let’s pull back the curtain on what’s happening when a prior authorization is required, and how you can partner with us to make the process smoother and faster.

💡 What Is a Prior Authorization?

A prior authorization is when your insurance company requires your doctor to get approval before they agree to pay for a medication, test, treatment, or procedure.

In theory, it’s meant to ensure appropriate use. In practice, it creates a frustrating delay in care for both patients and doctors, especially when the treatment is medically necessary and evidence-based.

🩺 What Happens Behind the Scenes?

From the outside, it might feel like everything is “on hold.” But here’s what’s happening in our clinic after your prescription or test order gets flagged for PA:

Certainly! Here's the same information reformatted as a clear, readable list—perfect for a blog post, email, or patient-facing handout:

🕒 What Happens Behind the Scenes During a Prior Authorization

When your prescription or test requires prior authorization (PA), here’s what we do on your behalf—and how long each step typically takes:

1. Notification (1–2 business days)
   We have been (hopefully) alerted by your pharmacy, lab, or imaging center that your insurance company requires prior authorization before covering the cost.

2. Chart Review (1 business day)
   My assistant and I review your medical history, recent symptoms, and treatment attempts to ensure we clearly explain why the medication or test is medically necessary.

3. Documentation (1–3 business days)
   We complete detailed insurance-specific forms, write a letter of medical necessity, and gather supporting materials, such as lab results, imaging reports, and visit notes.

4. Submission (same day)
   We fax or upload the whole packet of documentation to your insurance portal. Sometimes we have to submit it more than once if the system is delayed or incomplete.

5. Waiting Game (3–10 business days)
   The insurance company reviews your case. They may approve it, request more information, or issue a denial.

6. Appeal (if needed: add 5–7 business days)
   If denied, I may need to schedule a peer-to-peer phone call with an insurance medical director or submit a formal appeal letter with further documentation.

➡️ Total estimated timeline: 5 to 14 business days, depending on the complexity and how quickly your insurance responds. It can take longer if additional steps or appeals are required.

💊 Common Medications That Often Require PA

Even when the need is obvious, insurers may delay coverage for:

• Ozempic, Wegovy, Mounjaro (for diabetes or weight loss)

• Testosterone therapy

• CGMs (continuous glucose monitors)

• Newer ADHD or antidepressant medications

• Certain inhalers, injectables, and biologics

🧪 Tests & Services That May Require PA

• MRIs, CTs, PET scans

• Sleep studies

• Specialty labs (like GI-MAP, DUTCH, or pharmacogenomic testing)

• Infusions or high-cost injections

• Physical therapy or specialist referrals

Any procedure other than an ultrasound or X-ray essentially requires pre-approval from your insurance.

These are not fringe treatments—they’re often standard of care. However, cost or insurance policies can still trigger a PA.

🤝 How You Can Help Us Help You

You are not powerless in this process. In fact, there are specific ways you can speed things up and strengthen our case:

1. Share your full symptom story
   Be specific about when symptoms started, how they affect daily life, and what has or hasn’t helped.

2. Let us know what you’ve already tried
   If this is a medication PA, list any other drugs or treatments you’ve used, and whether they worked or caused side effects. (Even “it didn’t help much” is useful.) Insurance requires us to disclose this information, even though they should already have a record of it. They want to know the medication, dose, when you took it, and for how long, as well as any side effects or reactions you experienced.

3. Be open to a “trial” medication.
   Sometimes insurers require a step-wise approach: trying a lower-cost option first before approving the one we want. We can guide you through this if needed.

4. Watch your insurance portal or mail.
   Occasionally, you may get notifications before we do. Share any approval or denial letters you receive.

5. Consider out-of-pocket options
   Sometimes the cash price (via GoodRx, Mark Cuban’s Cost Plus Drugs, or our in-office pharmacy) is cheaper than using insurance, without any wait.

💬 A Note from Dr. Angela

When we prescribe something, it's because I believe it's the right step for your health, not because of trends, pressure, or shortcuts. We don’t get any kickbacks from pharmaceuticals for your medications (nor do most doctors, for that matter). 

And when insurance makes us jump through hoops, it doesn't mean you're not sick enough, or don't qualify—it means the system is flawed. But I will continue to advocate for you, document thoroughly, appeal when needed, and push back—because your health is worth it.

If you’re stuck in the PA process now, or the pharmacy has just told you that something “needs approval,” please don’t hesitate to reach out. We’re in this together—and we’re fighting for your care every day.

Why (non-DPC) Doctor’s Visits Feel Rushed

Why Doctor's Visits Feel Rushed

If you’ve ever felt that your visit to the primary care doctor was rushed, you're not alone. Many patients are frustrated by medical appointments' increasingly brief and impersonal nature. Let's delve into the reasons behind this and what it means for patient care, acknowledging the shared frustration.

Mal-aligned Incentives

In recent years, the healthcare landscape has shifted significantly. Large corporate entities, aka healthcare systems, have bought out many independent practices. These healthcare systems emphasize profitability and efficiency more than patient-centered care. The predominant reimbursement model in the US Healthcare system is “Fee-For-Service”(FFS). This model incentivizes volume (seeing more patients) over the quality of care.  In this model, insurances reimburse for direct care or patient visits. Some systems will counteract this by tacking on additional metrics to incentivize providers to improve “quality of care” (i.e., financially rewarding those who achieve a specific target percentage of patients above predefined metrics annually). The metrics vary yearly, but commonly measured things include the percentages of patients with controlled diabetes, controlled blood pressure, or the percentage of your panel up to date on colon cancer screening.  You may think this sounds good until you consider that a doctor with a panel size of 3000 patients (or more) likely has much less influence on those numbers than expected.  Quality metrics, short patient visits, and large panel sizes are a recipe for failure.  Improving outcomes requires time and trust. 

There is a push to re-align incentives with patient outcomes more comprehensively; however, this, too, has its limitations.    “Value-based care” (VBC) is a newer payment model that incentivizes providers to focus on quality outcomes rather than the quantity of services rendered. In VBC, the emphasis is on the overall health of the patient, rather than the number of visits or procedures. The potential benefits of VBC include improved patient outcomes, reduced healthcare costs, and a shift towards a more patient-centered approach. “The Centers for Medicare and Medicaid Services (CMS) has set a goal to have 100% of all Medicare beneficiaries tied to quality or value by 2030. Yet 40% of Medicare payments are still tied to Fee-for-Service as of 2020.” (Ahmed) Implementing VBC requires significant upfront financial and technology investments. Though it does stand to lower overall healthcare costs, it partially does so by limiting patient choice. Kaiser Permanente is an example of a healthcare system that has implemented VBC.

The Impact on Patients

Most of my patients come from FFS-based systems, so they are accustomed to 15-minute face-to-face visits (regardless of the patient issue) and long appointment wait times.  When I left my healthcare system, I had a panel of 3000 plus patients and a 3-6 mo appointment wait time.  Most appointments are “limited to “ your top 2-3 concerns; otherwise, schedule another appointment. Don’t think about bringing up new or chronic issues during your annual physical either; you get slapped with another co-pay for that visit (which is not always the doctor’s doing). This rushed atmosphere can lead to mistrust, overlooked symptoms, and a feeling of being unheard. It certainly does not leave room for lifestyle counseling and education.

The Impact on Doctors

Systematic time constraints place significant pressure on doctors. Because schedules are booked so far in advance, there are few slots for acute or simple patient visits.  Thus, most doctor schedules are packed with chronic conditions, complex medical cases, or comprehensive physicals. These tight schedules leave little time during the “work day” for paperwork, patient correspondence, and administrative tasks. The result? Work spills over into the evenings and weekends, and despite sacrificing sleep and time with your family, the work never ends.  Doctors in these environments must adapt to becoming cogs in the wheel or face moral injury. 

Lack of Continuity and Personal Connection

Another significant downside of the corporate medicine model is the lack of continuity in care. Patients are effectively not assigned to doctors; they are assigned to an office with a team of doctors and providers. There is certainly room for teams in medicine, however, not at the expense of the doctor-patient relationship. Fragmented care, sparse visits with your doctor, and time constraints lead to a lack of personal connection, making patients feel like just another number. Doctors feel the pain of this, too.  

A Way Forward

Direct primary care and other forms of independent practices are unlikely to meet the primary care needs of the whole population. However, I hope that by pushing the envelope and setting a new standard for primary care—quality over quantity, longer appointment times, and prioritization of the doctor-patient relationships—healthcare systems will have no choice but to change their practices. Maybe, just maybe, more students will choose primary care. 

Perks of a Chosen Family

While biological families play a significant role, chosen families—those friends and companions we select to be part of our lives—offer unique and profound health benefits. Here’s a look at how these cherished relationships positively impact our well-being:

1. Enhanced Emotional Support

Chosen family members often provide a level of emotional support that complements or even surpasses that of biological relatives. They understand us deeply and are there during life's highs and lows, offering empathy, encouragement, and a listening ear. This unwavering support helps reduce stress and promotes emotional stability.

2. Improved Mental Health

The companionship and understanding from a chosen family can significantly improve mental health. These relationships offer a sense of belonging and validation, which are crucial for combating feelings of loneliness, anxiety, and depression. Knowing that we have people who genuinely care for us enhances our overall mental well-being.

3. Increased Life Satisfaction

Having a chosen family can increase our overall life satisfaction. These relationships are built on shared interests, values, and mutual respect, making our interactions more fulfilling. Engaging with our chosen family brings joy, laughter, and a sense of purpose, contributing to a happier and more satisfying life.

4. Stronger Coping Mechanisms

Life's challenges are inevitable, but with a strong chosen family, we can navigate these difficulties more effectively. Chosen family members provide practical help and emotional resilience, whether it’s through advice, companionship, or hands-on assistance. This support system strengthens our ability to cope with stress and adversity.

Conclusion

The health benefits of the chosen family are multifaceted. These relationships offer emotional support, enhance mental health, increase life satisfaction, and bolster our coping mechanisms. In a world where traditional family structures are evolving, nurturing our chosen family is essential for a balanced and healthy life.

So, let’s recognize and celebrate the incredible impact of our chosen families. Reach out to those special people in your life, cherish these bonds, and embrace the profound health benefits they bring.

Finding Purpose: A Key to Health and Well-Being

In the hustle and bustle of daily life, it’s easy to overlook one of the most vital elements of a fulfilling existence: having a sense of purpose. Research shows that a clear sense of purpose can lead to numerous health benefits, including lower stress levels, better sleep, and increased longevity. But what exactly is “PURPOSE,” and how can you find yours?

Understanding Purpose

Purpose is the feeling that your life has meaning and direction. It gets you out of bed in the morning and drives you to pursue your goals. Whether living out your faith, raising a family, excelling in your career, or volunteering for a cause you’re passionate about, purpose gives your life a sense of direction and motivation. Regardless of your purpose, I firmly believe your purpose should involve an act of service to others. 

Health Benefits of Having a Purpose

1. Reduced Stress: Knowing your purpose and worth can help you navigate life’s challenges more resiliently.

2. Improved Mental Health: A strong sense of purpose is linked to lower rates of depression and anxiety.

3. Physical Health: Purposeful individuals enjoy better overall health and are likelier to engage in healthy behaviors.

Finding Your Purpose

1. Self-Reflection: Take time to think about what matters most to you. What are your passions, values, and strengths? Reflect on activities that make you feel energized and fulfilled. Are you currently giving your time and energy to things that you value? Are you presently engaging in activities that leverage your areas of strength?

2. Set Goals: Establish short-term and long-term goals aligning with your strengths, interests, and values. Having clear objectives can provide a roadmap to finding and living your purpose.

3. Explore and Experiment: Don’t be afraid to try new things. Engage in different activities, volunteer, or take up hobbies that interest you. These experiences can help you discover what truly resonates with you. Also, don’t be afraid to let go of things that don’t align with your strengths and values. 

4. Seek Connections: Build relationships with others who share your interests and values. Community and support networks can provide inspiration and motivation on your journey.

5. Reflect and Adjust: Discovering your purpose is often an iterative process. Periodically reassess your goals and activities to align with your evolving strengths, interests, and values.

Remember, your purpose doesn’t have to be grand or life-changing. Even small, everyday actions that align with your values and passions can contribute to a meaningful life. Start your journey to finding purpose today, and enjoy the myriad health benefits that come with it. 

At Seeds of Health, discussions about purpose are as common as blood pressure checks. We know how much this matters to your health and well-being because it matters to us, too.