Why is it so hard to get a prior authorization?
Asked by: Savannah Christiansen | Last update: May 27, 2025Score: 4.9/5 (29 votes)
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.
How to make prior authorizations 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 is prior authorization 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.
What happens if prior authorization is not obtained?
If you don't obtain it, the treatment or medication might not be covered, or you may need to pay more out of pocket. Review your plan documents or call the number on your health plan ID card for more information about the treatments, services, and supplies that require prior authorization under your specific plan.
Understanding 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.
Who is responsible for obtaining preauthorization?
The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient's insurance provider. As mentioned in the “How does prior authorization work?” section above, this will then often prompt a time-consuming back and forth between the provider and payer.
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.
Why is it taking so long for my prescription to be approved?
They review your medical information and PharmaNet profile to check for possible problems. This may include allergies or interactions with other medications you are taking.
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.
Can doctors see what other doctors have prescribed you?
as long as they are both actively working on a patient, then they should be able to access records. Yes, in many cases, doctors can see what another doctor has prescribed—thanks to advancements in healthcare technology and the need for better-coordinated patient care.
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.
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.
Why do insurance companies deny medications?
Insurance companies sometimes deny prior authorizations. They often will not approve a non-formulary product unless: A person has already tried their plan's preferred products. A person has an intolerance or contraindication to the preferred products.
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.
Why does it take so long for a prior authorization?
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.
Can a pharmacist override a doctor's prescription?
Can a pharmacist change prescriptions? In most cases, a pharmacist must follow the doctor's exact prescription, but there are a few exceptions. If the pharmacist finds interactions, dosing instructions, or other factors preventing the medication from working, a change may be necessary.
Why is it so hard to get a prescription?
There are several reasons why your pharmacist might not be able to fill your prescription. If your prescription is missing key information or hard-to-read, a pharmacy can refuse to fill it. Other reasons why your pharmacy may not have your prescription ready include insurance rejections or drug shortages.
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?
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.
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.)
Can a doctor's office charge for prior authorization?
Medicare does not require referrals or pre-auths. Some Medicare Advantage plans are starting this practice. Per CMS, you are not allowed to charge for any additional fees like pre-auths.
What happens if you don't get pre-authorization?
Prior authorization is not a guarantee that a claim will be approved, but failure to obtain prior authorization for a service that requires it will generally result in a claim denial, even if the health plan would otherwise have covered the service.
Can my doctor see if I picked up a prescription?
Does my doctor know if I filled my prescription? Pharmacies keep electronic and hard-copy records of all prescriptions filled in their store. Your doctor can always contact the pharmacy to see if you filled a prescription.