Why are prior authorizations so difficult?
Asked by: Rodolfo Lesch IV | Last update: May 20, 2025Score: 4.3/5 (32 votes)
How can I make my prior authorization easier?
- Create a master list of procedures that require authorizations.
- Document denial reasons.
- Sign up for payor newsletters.
- Stay informed of changing industry standards.
- Designate prior authorization responsibilities to the same staff member(s).
Why do prior authorizations take so long?
An insurance company's processing time for a Prior Authorization request depends on various factors, including the complexity of the request, the type of therapy or drug requested, and the insurance company's internal processes and workload.
Why do prior authorizations get denied?
Prior authorization denials create just one more barrier between patients and the medication they have been prescribed. Simple errors such as leaving fields blank, misspellings or failure to follow payer requirements are common reasons for denials that can be reduced with electronic prior authorization (ePA) solutions.
Can I get my medication without prior authorization?
Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs. Without prior authorization, your health plan may not pay for your treatment or medication. (Emergency care doesn't need prior authorization.)
The Prior Authorization Burden
Who is responsible for obtaining preauthorization?
How do I get a prior authorization? If your health care provider is in-network, they will start the prior authorization process. If you don't use a health care provider in your plan's network, then you are responsible for obtaining the prior authorization.
Which health insurance company denies the most claims?
According to the analysis, AvMed and UnitedHealthcare tied for the highest denial rate, with both companies denying about a third of in-network claims for plans sold on the Marketplace in 2023, respectively.
Is doing prior authorizations hard?
Prior authorization is a time-consuming, labor-intensive, and often frustrating process. Requests require several steps, and there's often a lot of back and forth with payers, especially if the initial request isn't accurate and complete.
How to fight prior authorization denial?
Whether a denial is based on medical necessity or benefit limitations, patients or their authorized representatives (such as their treating physicians) can appeal to health plans to reverse adverse decisions. In most cases, patients have up to 180 days from the service denial date to file an appeal.
How do I speed up a prior authorization prescription?
- Create a Master List of Medications That Require Prior Authorization.
- Document Denial Reasons Thoroughly.
- Stay Informed of Industry Standards & Payer Requirements.
- Assign a Dedicated Team for Managing Prior Authorizations for Medication.
Can a doctor's office charge for prior authorization?
Physicians and other healthcare providers do not usually charge for prior authorizations. Even if they wanted to, most contracts between providers and payers forbid such practices. However, there are some instances — such as when a patient is out of network — that it may be appropriate to charge for a prior auth.
Who handles submitting a request for prior authorization?
Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered.
Why is my prior auth taking so long?
But even when you're confident that you need to get pre-authorization, the manual process for your practice staff takes time. And because the forms and details regularly change as well, this often leads to delays. You might be able to obtain prior authorization within 24 hours.
How long should a prior authorization take?
How long does the prior authorization process take? It typically takes 24 to 72 hours.
What happens if the authorization is denied?
If your request for prior authorization is denied, then you and your patient will be notified about the denial. The first step is to understand the reason behind the denial, so contact the health insurance company to find out the problem. For example, a PA request for a medication might be rejected due to many reasons.
How can I make prior authorizations easier?
Create prepopulated forms, ideally using the insurer's own forms, listing codes, diagnoses, and other information the insurer typically requires to process a prior authorization. Submit requests electronically and use technology (a portal or EHR) to upload supporting documentation instead of faxing it.
How often are prior authorizations denied?
In March 2024, Forbes reported that “on average, 6% of prior authorization requests are initially denied. Of those, 11% are appealed, and 82% are ultimately fully or partially reversed.” If 82% of denials are reversed, why do only 11% of denials get appealed?
Why do some doctors not do prior authorizations?
Up to 92% of doctors say that prior authorization harms patient access to care, which ultimately damages clinical quality outcomes. While the process brings a certain accountability and cost containment; several hours are lost in productivity.
Who is the most trusted insurance company?
- Best for customer satisfaction: Erie Insurance.
- Best for seniors: Nationwide.
- Best for liability insurance: Auto-Owners.
- Best for claims filing : State Farm.
- Best for bundling: American Family.
- Best for accident forgiveness: Progressive.
- Best for military members and veterans: USAA.
How many claims before State Farm drops you?
Insurers, like State Farm or GEICO, do not have a fixed number of claims that automatically lead to policy cancellation. This is more likely to happen if you have three or more claims, a record of DUI, at-fault car accidents with high bodily injury and property damage costs and other traffic violations.
Do prior authorizations usually get approved?
About one-quarter of prior authorizations are denied, according to the AMA. If your health insurance plan denies your prior authorization request, you and your medical provider can appeal the decision.
Can I call my insurance about a prior authorization?
If you need to speak with someone in an effort to get your prior authorization request approved, the person most likely to help you is the clinical reviewer at the benefits management company. That person makes the decision to approve your prior authorization request, not someone at your health insurance company.
What are the pros and cons of prior authorization?
Prior authorization is also controversial, with both pros and cons: It does play a role in keeping medical costs down and promoting safe, efficient, and evidence-based care. But it's also burdensome for medical providers and often results in patients experiencing delayed care or abandoning the care altogether.