When prior authorization sparks ‘outrage and frustration’

In 2026, it may feel like every physician has not just one example, but a memorized catalog of anecdotes about problems with prior authorizations required by health insurers.

It should not have to be this way.

“The Invisible Hand Wielding the Scalpel: The Hidden Cause of America’s Healthcare Crisis,” is a book-length expose by Erica Rowe Urquhart, M.D., Ph.D., MBA. She is an orthopedic surgeon and staunch advocate for physicians’ ability to maintain private medical practices and provide the best, most cost-effective treatments for patients.

This excerpt comes from the introduction to her book. The case it describes may come as no surprise to fellow doctors. But it would be helpful in explaining to nonclinician family and friends why being a physician in contemporary American health care is so fulfilling and so frustrating at the same time. That is, if they’re not part of the ever-growing number of patients who have already felt the effects of delayed care.

Urquhart has joined the Editorial Advisory Board of Medical Economics.

Introduction

When Claudia Nichols lumbered into our office on crutches, I knew I wanted to help her… and her mother.

Hers was an all-too-common occurrence.

A young girl with a less-than-desirable insurance plan presented to the emergency room with an ankle fracture that was unstable. She required surgery, open reduction internal fixation, to fully recover from her injury. However, the original on-call team at the hospital where she was taken decided to defer definitive treatment. The ER doctor placed her ankle in a splint, gave her crutches, and instructions. Find a surgeon who participates in her plan.

By the time she and her mother found our private practice, 38 miles away, Claudia was nearing two full weeks after her initial injury, the time when all fractures begin to solidify, whether properly aligned or not.

“Dr. Urquhart, the room is ready. Can we bring your patient back?”

The charge nurse met me at the door of the operating room. She walked through the double doors of Room 7 while I followed.

“Let’s get started!” I nudged her with a smile.

I was relieved there would be no delays, but just as I was about to enter the operating room with the patient on the stretcher, I heard someone call my name from the front desk.

The nurse leaned over the counter, scratching her hair cover. Bending her head close to mine and speaking just loud enough for me to hear, she said, “It looks like there’s an issue with the next patient’s insurance. They’re waiting for you in the business office.”

What could be wrong? I walked to the door where patient finances were handled, realizing that until now, I had never entered the small room with its spartan desk and two hard chairs. Without preamble, Bryan, the business manager, said, “It’s USAChoice. The patient’s insurer is insisting on a waiting period, even though you and the hospital are in-network. They won’t green-light the surgery.”

“They what? Oh, they refused to issue the expedited prior authorization. Bryan, please get USAChoice on the line. Let me try to get the auth.”

He punched the numbers into the phone. “Hello, this is Bryan with the Medical Center calling back regarding patient Claudia Nichols. The surgeon would like to speak with you.” He handed me the receiver.

I reached for the telephone, my stomach growling. The mere thought of this conversation had my acid reflux acting up again.

“May I help you?” The man’s voice was clipped, detached, and cold.

“Yes, my name is Dr. Erica Rowe Urquhart, and I’d like to review the circumstances of this case. It is an orthopedic urgency because of the prior delay of emergent surgery…”

He interrupted, “The specific circumstances of Miss Nichols’ case are irrelevant. USAChoice’s policy is that this procedure is elective, and the 72-hour waiting period will be enforced … without exception.”

It was my turn to interrupt. “Do you mean that an adolescent who presented to an emergency room two weeks ago with an operative fracture has no alternative but to wait another week, until the fracture is almost healed, to have definitive surgical treatment? Just so you know, this is not the orthopedic standard of care.”

“That is correct. Not the standard of care part, but the authorization, as the expedited authorization was not granted. The surgery will not be authorized for 72 hours, or three business days. Is there anything else I may help you with?”

I imagined his smug face while I tamped down my outrage and frustration. “We’d like to appeal this decision to your supervisor. The OR is ready, the instruments are sterilized, and the trays have been opened. A significant investment of time and money has already been made by the hospital and our practice to get this young lady to the OR.”

“Doctor, our appeals process also requires a 72-hour timeframe for completion. The prior authorization will not be granted today.”

“She has to have surgery,” I said as if the insurance rep would listen. “Claudia’s fracture can’t be treated without an operation!”

He ignored my plea. “Have a nice day.”

I handed the receiver back to Bryan. “Dr. Urquhart,” he asked. “What was the verdict?”

“Bryan, I apologize for the delay. Unfortunately, Claudia Nichols will not be having surgery today. Let me deliver the news to the patient’s mother. Can you please call the operating room and ask them to help the patient get changed? She’s going home.”

I gave Claudia’s mother the news, watching her jaw drop, and her shoulders collapse. She swiped at her eyes. “I am so sorry.” I reached for her arm, projecting a calm demeanor I did not feel. “Our team did everything we could. USAChoice wouldn’t authorize Claudia’s surgery today. They are strictly enforcing a 72-hour waiting period.”

Horror stories like this are all too common in the United States healthcare system. Patients like Claudia are the hidden examples of America’s healthcare crisis. Too many patients are denied the timely care they need. Sadly, there are reports that as many as 75% of patients abandoned seeking care because of obstacles like Claudia experienced. Deny, Delay, Defer is the insurer’s playbook for dealing with patients seeking healthcare.

The process of obtaining care is increasingly inefficient. Doctors, nurses, and patients find themselves on hold for days or weeks, waiting for health insurance corporations to decide if a treatment plan is approved or denied.

As Claudia’s case demonstrates, corporations — healthcare insurers — are treating healthcare as a commodity, and that is a radical turnaround from the value of patient care my fellow doctors and I learned in medical school when we swore to uphold the Hippocratic Oath.

Should accessing the healthcare our insurance premiums pay for be so difficult or take so long? No.