Guest Commentary | ‘Prior authorization’ remains a pain point for physicians, patients
Physicians devote the early part of their careers to education and training. They spend years honing and refining their clinical skills through medical school, internships, residencies and fellowships. Finally, they are ready and eager to step out on their own and start seeing patients.
And then, they’re met with the reality of practicing medicine in 2026 – paperwork.
Written documentation is a critical part of health care, of course. That’s why most medical offices employ a team of receptionists, medical coders, records clerks, billing specialists and office managers. However, physicians are devoting more of their workday as pseudo-lobbyists convincing insurers to cover the cost of procedures, treatments and prescription medicine.
The term “prior authorization” describes the insurance process requiring medical providers to obtain approval from insurers before providing a health care service, including surgeries and treatments. In some cases, it can be as simple as forwarding a patient’s medical form along with a doctor’s letter of medical necessity. At times, though, the process can be cumbersome, time consuming and downright discouraging.
In my line of work – cancer treatment – there are often multiple options to consider: radiation, surgery, chemotherapy, immunotherapy, hormone therapy, bone marrow transplants and targeted therapy. In many cases, physicians recommend a combination to confidently eradicate cancer cells and tumors.
I have been delivering proton therapy since the start of my training. Proton therapy is a highly advanced form of radiation therapy that uses charged proton particles to destroy cancer cells with exceptional precision. Proton beams deposit high-energy doses of radiation directly into a tumor, and stop there, so there is no exit dose passing through healthy tissue on the opposite side. This typically results in fewer side effects and less overall radiation exposure to healthy tissues.
Physicians often recommend proton therapy for pediatric malignancies, curable brain tumors, tumors of the skull base and spine, eye tumors and select patients with breast, esophageal, head and neck, liver, lung, prostate, lymphoma and sarcoma cancers. Proton therapy is exceptional for treating tumors near critical organs and for pediatric cancer in which long-term risks must be minimized. It’s also a good option for patients who already have received radiation to treat a previous cancer.
Numerous research studies have confirmed that proton therapy offers superior outcomes for patients with a variety of cancer types. Insurers are always looking at their bottom line, and whether it’s proton therapy, PET scans, prescriptions or pain management, finances will continue playing a role in their decision to approve requests.
Health care professionals strive to provide the best care possible, allowing the numbers to work themselves out. If proton therapy offers the best possible outcome, then that’s what I’ll recommend every time.
In the legal system, defendants are considered innocent until proven guilty. In medicine, it’s essentially the opposite – claims are effectively denied unless a physician can prove, beyond a reasonable doubt, that a recommended treatment is medically necessary.
The prior authorization process is understandably essential, and fortunately, insurers often expedite requests in emergency situations like surgeries and cancer treatments. Delays can frustrate doctors and stress out patients.
In many cases, the people making decisions on whether to approve a treatment have backgrounds in medicine. However, they are employed by insurance companies that must remain profitable, and treatment costs matter to number crunchers and accountants.
Physicians shouldn’t have to beg and plead with insurers to cover the cost of lifesaving treatments. They spend years researching and practicing medicine. Why can’t we just trust their judgment?
Dr. Todd Pezzi is a board-certified radiation oncologist and associate medical director at Southwest Florida Proton in Estero.