Prior authorization means healthcare providers must get approval from a patient’s insurance company before they can provide certain treatments or medicines. The insurance company checks if the treatment is needed, matches their rules, and helps control costs. At first, this system was for expensive new drugs, but now it covers many generic drugs and many types of procedures and services.
Doctors in the U.S. send about 39 to 45 prior authorization requests every week. Each request involves lots of paperwork, phone calls, and sometimes faxes. Doing all this can take about 14 hours per doctor each week. Usually, office staff or other medical team members handle this work. This extra work affects how medical offices run and how doctors feel about their jobs.
Doctors and their staff often find prior authorization rules difficult. A 2024 survey by the American Medical Association (AMA) asked 1,000 doctors. About 89% said prior authorization makes doctors feel more tired and stressed. This happens because doctors spend less time with patients and more on paperwork. Staff spend many hours dealing with different insurance rules, repeated denials, and time-consuming discussions with insurance reviewers. Around 65% of doctors take part in these discussions, but sometimes the reviewers do not have enough medical knowledge.
Managing prior authorizations also costs money. It can cost between $2,161 and $3,430 per doctor each year. This money goes to pay extra staff or overtime. The AMA and the American College of Physicians (ACP) say prior authorization is one of the main reasons medical work is complicated and takes time away from patient care.
Delays from prior authorization can hurt patient treatment and results. More than 90% of doctors say prior authorization causes delays. About 82% say these delays make patients stop their treatments. When patients do not get their medicines or treatments on time, their health can get worse. This can lead to emergency room visits or hospital stays. AMA data shows that 42% of doctors see emergency visits linked to prior authorization delays. Also, 29% see hospital admissions tied to these delays.
Prior authorization can also make patients try treatments that might not work as well. For example, a doctor in New Jersey told about a diabetic patient who had stomach problems after being forced to change to a generic medicine because of prior authorization rules. When treatments do not work well, this can increase healthcare costs. In a survey, 86% of doctors said prior authorization actually raises healthcare spending instead of lowering it.
One big problem with prior authorization is that it is hard to predict. Doctors and staff often do not know exactly what information insurance companies want. This leads to sending requests again, making appeals, and having many discussions. Many requests are denied even when the treatment is clearly needed. Almost 40% of doctors say prior authorization requests are “often” or “always” denied, which means a lot of extra work to appeal.
Sometimes, people reviewing these requests are not doctors and lack medical training. This can cause wrong denials and more delays. Only about 16% of doctors say that reviewers usually have the right skills to judge if a treatment is needed. This unclear process makes doctors and staff frustrated and slows down medical work. Patients feel unhappy with the delays too.
Healthcare workers get tired and stressed because of prior authorization tasks. Medical assistants, nurses, and office staff spend a lot of time on tasks like scheduling, entering data, and calling insurance companies again and again. U.S. healthcare workers together spend thousands of hours on these tasks. This slows down how clinics work.
Also, patients with low income, less education, disabilities, or long-term illness find it harder to deal with these complicated insurance rules. They may miss or wait too long for needed care.
Employers also notice problems. About 53% of doctors said prior authorization delays hurt patients’ job performance. This leads to less work done and more missed work days.
Prior authorization costs a lot of money. Last year, the U.S. healthcare system spent $1.3 billion on prior authorization work. This is 30% more than the year before. Each prior authorization request costs about $6 to handle. This adds extra costs for doctors and health systems.
Patients also pay more. Nearly 80% of doctors said that when prior authorization is denied or delayed, patients sometimes have to pay for medicines themselves. This can make patients skip treatments and hurt their health.
The delays, appeals, and denials use healthcare resources inefficiently. More doctor visits, emergency room trips, and hospital stays add costs that may be more than the money saved by insurance companies restricting treatments at first.
Many groups and government agencies are trying to fix the problems with prior authorization:
Even with these efforts, most doctors say there has been little real change in the number of prior authorizations or how long they take, especially from big insurers like UnitedHealthcare and Cigna.
Artificial intelligence (AI) and automation tools can help reduce the extra work caused by prior authorization in medical offices. Some companies, like Simbo AI, work on automating tasks like phone calls and data handling related to prior authorization.
AI can help medical offices by:
With AI tools, IT managers and administrators can make office work smoother. This lets healthcare staff spend more time with patients. It also may save money and reduce doctor burnout from prior authorization work.
For people who run medical offices, the rising number and difficulty of prior authorizations cause many problems:
Spending on automation and AI systems for prior authorization can reduce these problems by cutting down on paperwork and speeding up approval times.
In its current form, prior authorization causes a lot of extra work, delays patient care, and raises costs in the U.S. healthcare system. Doctors and staff spend many hours handling these requests, while patients face delays and extra costs.
Government agencies, advocacy groups, and states are working to improve prior authorization rules. But many medical offices still deal with unclear insurance rules and tough workflows. New tools using artificial intelligence and automation could help reduce these problems and let healthcare focus more on patient care.
Medical practice leaders should review their prior authorization steps and think about using technology to make work easier, lower staff stress, and improve care for patients.
Prior authorization is a process where insurance companies require physicians to obtain approval before covering medications or treatments. It was initially designed to control costs by limiting expensive, new medications. Over time, it has expanded to include a broad variety of drugs and treatments, aiming to reduce insurer spending.
Prior authorization complicates clinical decisions because physicians must predict which treatments insurers will approve, creating uncertainty. This process delays care and frustrates both doctors and patients as coverage details are opaque, preventing effective collaborative treatment planning.
Doctors often do not know the exact information insurers require to approve a request, leading to multiple rounds of explanations. Non-physician reviewers unfamiliar with specific diseases may reject valid requests, causing inefficient use of time and resources.
Physicians fill around 45 prior authorization requests weekly on average, with significant time devoted to paperwork and appeals. Many practices assign specific staff to handle these burdensome, time-consuming tasks, detracting from patient care.
Prior authorization delays can prevent timely treatment, leading to worse health outcomes and hospitalizations. Some patients become frustrated and abandon needed medications, with studies showing up to one-third fail to pick up prescriptions due to these barriers.
Yes, it has grown from focusing on new, expensive medications to including common generics and a wide range of treatments. This unpredictability means even long-established medications may require prior authorization.
Patients stable on chronic medications may face repeated prior authorization requirements during refills. Insurance denials, even when patients improve on treatment, force unnecessary paperwork and risks destabilizing patient health by forcing stops in effective therapies.
The system is unpredictable, constantly changing, and riddled with inappropriate denials requiring slow, burdensome appeals. Physicians often complete all paperwork but face delayed insurer responses, which hinders timely patient care and adds administrative burdens.
The AMA has collaborated with insurers and pursued legislative action at state and federal levels after failed industry negotiations. Several states have enacted reforms, and Congress is considering bills targeting issues in programs like Medicare Advantage.
Patients can share their experiences with prior authorization challenges via platforms like FixPriorAuth.org, contact legislators to highlight care delays, and keep their physicians informed about pharmacy-related prior authorization issues to aid advocacy and prompt action.
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