Ethical Obligations and Duty to Advocate for Patients in Prior Authorization for Surgery

Patients expect the timeliness of our efforts, particularly if delay would be detrimental to their health issues. It is also important for the otolaryngologist, whether or not they have had previous denials for similar requests, to anticipate possible payer objections prospectively and to address them in the initial prior authorization request. Certainly, if an appeal is required, every denial objection must be countered with evidence-based data and thoughtfully reasoned responses. At the onset of the prior authorization process, the otolaryngologist would do well to outline for the patient/family the prior approval procedures and any variations owing to public or private payers, to help them understand the mechanisms and where a delay might occur. If second opinions would be helpful for the request or appeals, then that further information-gathering process must be facilitated, especially if it is likely to have a favorable impact on a decision.

Obtaining prior authorization can be a drawn-out effort. Patients and family members may become impatient with delays, so active listening and effective communication by the otolaryngologist are key elements in moving the authorization forward. Timelines expressed to the patient must be realistic, and the risks of delays should be fully explained. Yet, a positive outlook and hope are products of effective otolaryngologist communication skills. Significant delays and denials can be morally stressful for both surgeon and patient/family units, requiring attention to their well-being and continued dedication to the task.

When prior authorization requests and appeals are all denied, then the otolaryngologist needs to redouble their efforts and consider more aggressive and creative approaches. This might include requesting hospital or institutional support, with the claim of overcoming systemic barriers to care, or using federal oversight reports (Office of the Inspector General, state oversight and advocacy departments) in further appeals when denials contradict coverage rules and general best clinical practice guidelines. Engaging with specialty societies’ advocacy experts to join the effort should be in alignment with the societies’ stated mission and goals for patient support, and their advocacy for system-level reforms that reduce arbitrary or indifferent approaches to prior authorization requests on behalf of patients. Finally, while not necessarily encouraged, social platforms that allow donations to families for needed surgery might be the answer.

When otolaryngologists advocate effectively for their patients, they uphold beneficence, prevent harm, respect patient autonomy, and promote distributive justice. Patients judge an otolaryngologist’s commitment to them not only by skill in the operating room, but also by their dedication to removing barriers to their care. For otolaryngologists, as for all physicians, professional and personal integrity are strongly linked in a physician’s approach to fellow human beings.