Many appointments with a neurologist end with the physician recommending tests, procedures, and medications. But in some cases, a patient may have to wait to follow the doctor's orders because they first need approval for payment from their health insurer. Your doctor may have to seek approval for a new test or new or expensive therapies through a process called prior authorization.

Health insurers request prior authorizations for financial, not medical, reasons. They also may require a prior authorization for routine studies or even a medication the patient is already taking. The doctor must fill out paperwork explaining why a test or new therapy is necessary.

Insurers do not grant all requests for prior authorizations, however. An insurer can deny the doctor's orders, which may result in an appeal or the doctor switching to an alternative, and sometimes inferior, option. The doctor's office, not the patient, can file an appeal with the health insurer, but a reply can take days to months.

In response to an appeal for a particular prescription drug, the insurer may want the patient to undergo “step therapy,” in which the patient must try a less expensive drug first—and not respond well to that drug—before the insurer will consider the originally prescribed medicine. For some patients, this delay in starting the prescribed medication can result in irreversible nerve damage and/or disability.

Doctors generally can check with an insurer ahead of time to see if it will cover a particular test. (Patients may still have to pay a copay.) The doctor and patient may not know whether a prior authorization is required for a particular medication, however, until the patient gets to a pharmacy and learns about the requirement from a pharmacist.

If the pharmacist tries to bill the insurer and finds out that the insurer needs a prior authorization, the pharmacist will let the physician know, but patients should contact their doctor's office as well. The office then will start the process of requesting a prior authorization, filling out paperwork to explain the medical necessity of the decision. The insurer may take days to weeks to respond, and if they turn down the request, the physician can appeal.

While waiting for a prior authorization or appeal to come through, patients can reach out to their doctor to learn about any alternatives. The doctor may be able to put a patient on another medication that may be less expensive and covered by insurance but not necessarily as effective.

Doctors may be able to obtain free samples of the originally prescribed drug for patients’ use as well. Pharmaceutical companies also may have programs in which they offer the drug at a reduced cost for a specific period of time.

Other options for the waiting period include paying out of pocket, if the patient can afford to, or reaching out to a health care foundation to see if it can cover the cost. The doctor's office may have a social worker or other staff member who can help, too. Or, ask the patient association for that particular health condition if it offers payment assistance.

Doctors have lately found that more drugs now require prior authorization before a pharmacy can dispense them. A refill request can trigger the need for prior authorization as well, even if the patient has been on the drug for years.

The American Academy of Neurology and other medical societies, including the American Medical Association, are working with Congress to develop legislation that could change prior authorization rules to make it easier for doctors to prescribe the best treatments for their patients. Some states already have legislation that limits step therapy and makes it easier for patients to access the medication their neurologist has prescribed.

Dr. Markowksi is a neurologist at Spaulding Rehabilitation Hospital in Massachusetts.