Why Your Prior Authorization Might Be Stuck (and It Isn't Always the Insurer)
A patient called me agitated that a procedure they were counting on was at risk. It was scheduled for later in the week, but the prior authorization still wasn't approved.
The patient was anxious and in pain. The doctor's office was frustrated. Both placed their displeasure squarely on the health plan.
That is understandable. We trust our doctors more than our insurers. The clinical team has done the diagnosis, made the recommendation, and answered our questions face to face. The health plan is a phone tree and a denial letter. The prior authorization process by itself is a net negative for patients and doctors and can be considered the root cause of the problem . So of course the blame defaults to the plan.
But in this case, it's the doctor's office that could have made this smoother.
This patient's health plan was required to respond to this prior authorization within 7 calendar days. (An urgent request requires 72 hours turnaround). The doctor's office submitted this one 11 calendar days before the appointment despite the appointment having been originally scheduled months ago. Four days after the submission, the plan denied the request due to a missing test. The office and the patient then scrambled, got the test done, and resubmitted the same day at great inconvenience to the patient. Unfortunately, the new submission reset the 7-day clock. So the appointment was still possible, but there was no margin left; another hiccup and the appointment would be missed.
The patient's pain relief may be lost or delayed, because of paperwork timing the patient never knew was happening.
Your doctor's workload
I want to be careful here. The doctor's office could have handled this better by submitting earlier and confirming criteria before sending the first request (though health plans' decision making can be hazy). But blaming the office isn't useful, because the office isn't sitting on its hands.
According to the American Medical Association, the average office completes 40 prior authorizations per physician every week, and staff burn roughly 13 hours a week on prior authorizations alone. 40% of physicians have staff who work exclusively on prior authorizations. Different plans, different forms, different documentation rules, different turnarounds. That's quite a workload.
While providers bear financial risk for missed appointments, it's the patient that really bears the burden. Thus patients have the strongest incentive to make sure the wheels are turning.
What to do
Prior authorization is not a one-time event. It's a process with a clock, a set of requirements you often can't see, and several places it can fall apart. The patient who follows up early and respectfully tends to get better outcomes.
If you've been told a procedure or medication needs prior authorization, treat it as a process you co-own with the office. And if you haven't been told, ask whether a prior authorization is required.
Ask the doctor's office when they plan to submit. Don't assume it goes in the day the doctor recommends the treatment. Ask them to submit as soon as possible. You aren't being pushy. You're giving everyone room to recover from a hiccup.
Ask what the plan requires. Different plans have different documentation rules for the same procedure: chart notes, imaging, prior treatment history, specific lab values. Ask the office whether they've confirmed the plan's current requirements for this specific authorization. If they haven't, ask them to. A quick check before submission can prevent a denial you'd otherwise be scrambling to fix.
Ask if the authorization request can be considered urgent. If it can be, then the health plan will react more sooner.
Have a Plan B conversation early with the doctor's office. Ask the office what happens if it isn't approved in time. Reschedule? Resubmit as urgent? Appeal?
Confirm the submission and record the date. You can find information about prior authorization requests made on your behalf in your health plan member portal. Then you'll have information from both sides; monitoring all parties in the process is helpful since your role may (unfortunately) require you to coordinate between them or hold them accountable to deadlines.
Check in with both parties after submission but before the turnaround deadline. Note your health plan customer service may not have visibility into the authorization decision making process, but they'll be able to explain terminology or next steps if needed. Your doctor's office will have the details if their request is denied.
Always document dates, times, and the names of people with who you speak.
You can both trust your doctor's clinical judgment and still verify the office's administrative work. Being a good patient does not mean being a quiet one. Always remember to be respectful; the process isn't easy for the person who's assisting you either.
If you're in the middle of a prior authorization that feels stuck, or a denial that came back when it shouldn't have, Peak Health Advocates does this work for clients every day. peakadvocates.com/contact
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