Prior Authorization: Strategies to Reduce Delays
Prior authorization requirements delay care and burden staff. The average practice spends 14 hours per week on prior authorizations. Here’s how leading practices streamline the process while maintaining compliance.
The Prior Authorization Problem
The statistics are concerning:- 93% of physicians report care delays due to prior authorization
- 34% of physicians report patient harm from prior authorization delays
- Average time to complete a prior authorization: 2+ business days
- Appeals success rate: 75%+ (meaning many initial denials are inappropriate)
Strategy 1: Front-Load the Work
Check authorization requirements at scheduling, not after services are ordered:- Integrate authorization checking into scheduling workflows
- Maintain lists of services requiring authorization by payer
- Verify authorization status 48 hours before scheduled procedures
- Have backup dates available if authorization isn’t obtained in time
Strategy 2: Use Electronic Submission
Payer portals are faster than phone or fax:- Register for all payer authorization portals
- Train staff on portal navigation
- Track portal submission metrics vs. phone submissions
- Escalate to phone only when portal status is unclear
Strategy 3: Document Thoroughly
Strong documentation reduces denials and strengthens appeals:- Document medical necessity clearly in the clinical note
- Include relevant history, failed treatments, and clinical urgency
- Attach supporting documentation proactively
- Reference payer clinical guidelines in your submission
Strategy 4: Track Authorization Expiration
Expired authorizations are a common cause of denials:- Build authorization expiration tracking into your system
- Set alerts for authorizations expiring within 30 days
- Begin renewal process well before expiration
- Verify authorization status before each scheduled service
Strategy 5: Know Your State Laws
Several states have enacted prior authorization reform:- Gold carding laws reduce requirements for providers with good track records
- Response time requirements mandate payer turnaround times
- Continuity of care provisions protect ongoing treatments
- Transparency requirements give visibility into approval criteria
Strategy 6: Appeal Appropriately
When authorizations are denied:- Review the specific denial reason
- Gather additional supporting documentation
- Request peer-to-peer review when appropriate
- Track appeal success rates by payer and service
Measuring Success
Key metrics to track:- Time from order to authorization approval
- First-pass authorization approval rate
- Appeals volume and success rate
- Services delayed or cancelled due to authorization
