“In the time it takes to get prior approval, a patient's condition may get worse. That's not care. That's a delay.”
Healthcare in the United States is known for innovation, but one outdated process continues to stall progress: prior authorization. It was designed to control costs. But now, it often slows care. As a result, providers and patients both get frustrated due to the long wait. And in medicine, waiting often hurts outcomes.
Prior Authorization Is Meant to Help, But It Doesn't Work Like It Should
Prior authorization (PA) aims to ensure treatments are medically necessary. It's supposed to reduce unnecessary care. In reality, it often feels like red tape. Physicians know what their patients need. Yet, insurers force them to submit paperwork, wait days—or even weeks—then jump through more hoops when denials come back.
This process eats into clinical hours. Staff must fax forms, call payers, and track responses. It pulls attention from patients and shifts it to paperwork. Worse, many approvals are for treatments that providers would never request without valid reasons. So, the process rarely stops misuse—it just delays timely interventions.
The Numbers Show the Damage
A recent survey by the American Medical Association (AMA) in 2024 shows just how harmful PA has become. Over 89% of physicians reported that prior authorization leads to delays in care. Even more alarming, 24% said it has led to a significant adverse event for a patient in their care.
These are not isolated stories. Across the country, the adverse effects of prior authorization delays are as follows -
- Doctors are canceling procedures
- Patients are left in limbo
- Follow-ups are missed
The process meant to control costs now adds to them. Hospitals rebook tests. Clinics spend hours chasing faxes. Every step costs time, money, and trust.
Doctors Are Overwhelmed by Administrative Burden
In an average week, medical practices complete hundreds of prior authorizations. Many require phone calls, multiple forms, and insurer-specific portals. That's time taken from actual patient care.
Nurses and admin staff handle most of these tasks. But they aren't clinical decision-makers. When insurers deny requests, physicians must jump in. They write appeal letters, collect documents, and often attend peer-to-peer reviews. That adds more pressure on an already overloaded system.
Doctors go into medicine to heal, not to navigate insurance bureaucracy. Many report burnout and moral distress because they can't offer timely care.
Patients Lose Trust When Care Is Delayed
Most patients don't understand how prior authorization works. All they know is that their treatment was canceled—or didn't happen on time. They trust their doctors. When delays happen, they often blame the provider.
This erodes the provider-patient relationship. It also creates anxiety for patients waiting for critical procedures or medication. Chronic pain sufferers must often wait weeks for approvals. People with progressive diseases may see their condition worsen.
Every delay leads to increased suffering. And that makes the healthcare system feel cold, confusing, and unresponsive.
The Electronic Promise Falls Short
Payers and tech companies introduced electronic prior authorization (ePA) to streamline the process. The idea is to reduce faxes and automate decisions. But many providers say it's not widely adopted, nor is it standardized across payers.
Some portals are clunky. Others don't show real-time updates. Many still require manual input. This turns a digital promise into another digital problem. While the concept is strong, execution still lags.
For ePA to work, systems must be universal, intuitive, and fast. Until then, providers continue faxing documents in a digital world.
Transparency Is Missing from the Process
Lack of clear medical necessity is another major issue related to prior authorization. Most insurers don't explain their PA criteria clearly. Providers often guess what documentation to send. Denials arrive without clear reasoning. Appeals take weeks, sometimes months.
It's like trying to win without knowing the rules of the game. That doesn't help doctors. And it certainly doesn't help patients. Transparency in medical necessity guidelines and faster turnaround times could solve a huge part of the delay.
Outsourced Prior Authorization Companies Offers a Feasible Solution
The solution isn't to remove prior authorization entirely, but to use it wisely. Here, third-party prior authorization services streamline the process. They must follow the steps below:
Gold Carding: Providers who have an appropriate care history usually get automatic approvals. This builds trust and speeds PA requests.
Clinical Decision Support Tools: Integrated with electronic health records (EHRs), these tools can offer real-time guidance on what requires PA, saving time.
Standardized Forms: A single, national format would reduce confusion. One form for all payers—clearly outlining needed documentation—could eliminate unnecessary back-and-forth.
Regulatory Pressure: Legislative support is critical. CMS has proposed faster timelines for Medicare Advantage PA approvals. If passed, private insurers may follow.
These steps require collaboration across the board. But most importantly, they put patients back at the center, where they belong.
Finally, Care Shouldn't Wait for Paperwork
Prior authorization may have a role in preventing waste. But today, it causes harm. Delays in cancer treatments. Missed therapy sessions. Postponed diagnostic imaging. These aren't small problems—they're life-altering. Here, outsourcing offers effective and most affordable solutions.
The outsourced prior authorization companies also offer end-to-end RCM services. Moreover, they reduce accounts receivable with effective strategies. With their assistance, providers can not only secure approval in a timely manner but also reduce 80% of operational costs. Hence, outsourcing offers a win-win situation for both providers and payers.
