How long should I wait for a prior authorization?

Yes, prior authorizations do get denied by health insurance companies.

Denial rates typically range from 2% to 25% depending on the insurer and plan type (such as Medicare Advantage or ACA Marketplaces), averaging around 12% to 18% overall.

Common Reasons for Denials

• Missing or incomplete documentation: Clinical notes, test results, or medical history required by the insurer are absent.
• Lack of medical necessity: The insurer decides the treatment is not fully justified based on their guidelines.
• Step therapy not met: The patient has not tried and failed a cheaper, required alternative first.
• Service not covered: The requested drug or procedure is excluded under the specific policy.
• Administrative errors: Incorrect billing codes or missing patient information are submitted.

What to Do If Denied

• Review the denial letter: Find the exact reason for the rejection and any instructions or deadlines for an appeal.
• Partner with your doctor: Ask your physician's office to supply missing clinical notes, lab results, or a letter of medical necessity.
• File an appeal: A large portion of initial prior authorization denials are overturned when extra documentation is provided during the appeal process.

Many health insurance plans require prior authorization (pre-approval from the insurance company before they will cover the cost) for specialty, high-cost, or controlled medications. Three common examples of drugs that frequently require prior authorization include:

• Ozempic (semaglutide): Often prescribed for type 2 diabetes, insurers frequently require prior authorization to ensure it is being used for an approved medical condition rather than off-label cosmetic weight loss, or to verify that step therapy requirements (trying preferred alternatives first) have been met.
• Botox (onabotulinumtoxinA): While widely known for cosmetic use, therapeutic applications like chronic migraine prevention, severe muscle spasticity, or bladder dysfunction routinely require prior authorization from insurance to confirm medical necessity.
• Humira (adalimumab): As an expensive biologic medication used for chronic inflammatory conditions like rheumatoid arthritis or Crohn's disease, plans require prior authorization to verify diagnosis criteria and ensure patients have tried standard first-line treatments (such as traditional nonsteroidal anti-inflammatory drugs or methotrexate) without success.

Doctors dislike prior authorization because it creates heavy administrative work, delays patient care, and undermines their clinical judgment.

Heavy Administrative Burden

• Wasted time: Doctors and their staff spend roughly 12 to 16 hours every week filling out forms, faxing documents, and waiting on hold.
• Burnout: Managing dozens of authorization requests per doctor each week contributes significantly to staff fatigue and physician burnout.
• Frustrating reviews: The "peer-to-peer" appeals often require doctors to justify clear medical decisions to non-physicians or reviewers outside their specific medical specialty.

Harm to Patients

• Care delays: Over 90% of physicians report that the approval process delays necessary medical treatment or prescription refills.
• Adverse health events: Surveys by the American Medical Association show that one-third of doctors report prior authorization leading to serious medical outcomes like hospitalizations or permanent disability.
• Treatment abandonment: Many patients give up and stop trying to get care when facing complicated insurance roadblocks.

Distrust of Insurance Motives

• Second-guessing expertise: The process requires doctors to get a third-party corporate insurer's permission to practice medicine they already trained years to perform.
• Cost-cutting focus: Clinicians feel the system is designed primarily to boost insurance company profits by blocking or delaying costly treatments rather than improving health.

A common reason for a prior authorization rejection is missing or incomplete clinical documentation. Insurance companies often reject requests because they lack required lab results, imaging reports, or clinical notes.

Other Common Reasons

• Lack of Medical Necessity: The submitted details do not prove the treatment or medication meets the payer's clinical guidelines.
• Coding Errors: The CPT (procedure) or ICD-10 (diagnosis) codes are wrong or do not match.
• Step Therapy Requirements Not Met: The patient did not try or fail lower-cost, preferred alternative treatments first.
• Non-Formulary Drugs: The requested medication is not on the insurance plan's approved drug list.

A doctor's office typically submits a prior authorization request within 1 to 5 business days of prescribing a medication or scheduling a procedure, though the actual insurance company review takes an additional 24 hours to 14 days depending on urgency.

Submission by the Doctor

• Standard Submissions: Most clinic staff complete and send the paperwork within 2 to 3 days, depending on their workload and whether they use fast electronic systems (ePA) or older manual methods like faxing.
• Urgent Submissions: If a condition is severe or life-threatening, doctors can flag the request as urgent and often submit it the same day.

Review by the Insurance Company

Once the insurance company receives the form from the doctor, the review timeline varies:

• Urgent Requests: Usually processed within 24 to 72 hours.
• Standard Requests: Typically take 2 to 10 business days (and up to 14 calendar days for certain Medicare Advantage plans).
• Common Delays: Missing clinical notes, incorrect insurance codes, or requests for extra proof of medical necessity can stretch the entire process to several weeks. Opinions on Reddit forums regarding specific drugs like Mounjaro show that while some approvals happen in under 24 hours, others stall for weeks due to administrative errors.