Prior Authorization: The Hidden Tax on Your Doctor's Time
Prior Authorization: The Hidden Tax on Your Doctor's Time
5 minute read
Before your doctor can prescribe certain medications, order specific tests, or refer you to a specialist, they often have to ask your insurance company for permission. This process is called prior authorization, and it is consuming an extraordinary amount of the time your doctor could be spending on patients.
The numbers are striking. A 2023 survey by the American Medical Association found that physicians and their staff spend an average of 34 hours per week on prior authorization tasks: filling out forms, making phone calls, waiting on hold, uploading documentation, and managing denials.¹ For a small practice, that can represent the equivalent of nearly a full-time employee doing nothing but insurance paperwork.
This is not just an administrative inconvenience. It affects your care in ways that are direct and sometimes serious.
How Prior Authorization Works (And Where It Breaks Down)
Prior authorization is ostensibly a quality and cost-control tool. The idea is that before expensive or potentially inappropriate treatments are delivered, an insurer reviews whether they meet clinical coverage criteria. In theory, this prevents unnecessary care and keeps premiums down. In practice, the system has expanded far beyond its original purpose.
The volume of prior authorization requirements has grown dramatically. The AMA survey found that physicians complete an average of 43 prior authorization requests per physician per week.¹ The vast majority of those requests are ultimately approved, which raises a legitimate question about what the process is actually accomplishing versus how much friction it is creating.
Prior authorization requirements have been applied to an increasingly broad range of treatments, including generic drugs that have been on the market for decades, standard diagnostic imaging, and routine referrals to specialists. The American Academy of Family Physicians reports that prior authorization delays have led to care abandonment, meaning patients gave up on recommended treatments because the authorization process was too difficult to navigate.²
When the process breaks down, here is what happens to you. Your doctor submits a prior authorization request. The insurer requests additional documentation. Your doctor's office submits it. There is a delay. Another request for information arrives. More delay. Meanwhile, you are waiting for a medication or a procedure that your doctor has already determined you need.
A 2022 AMA survey found that 34 percent of physicians reported that prior authorization delays had led to a serious adverse event for a patient.¹
What This Means for the Doctor-Patient Relationship
The administrative burden of prior authorization does not fall only on physicians. It falls on patients, too, in ways that are less visible but equally real.
When your physician's staff is spending hours each week on authorization paperwork, that time is not available for patient care. When your doctor has to spend part of your appointment navigating an electronic prior authorization portal or making a call to a utilization management company, your appointment gets shorter. When a prior authorization for a referral takes two weeks, your specialist appointment gets pushed back.
There is also a subtler effect: physicians sometimes modify their prescribing behavior to avoid the prior authorization burden. A prescription that requires hours of paperwork to justify may be replaced with a less optimal option that does not require authorization. This is a known phenomenon, documented in medical literature, called prescribing avoidance, and its consequences for patient care are difficult to measure but real.³
A 2019 study found that 28 percent of physicians reported prescribing an alternative medication specifically to avoid prior authorization requirements, even when the alternative was not their first clinical choice.³
What You Can Do as a Patient
You are not passive in this process. There are several things you can do to help move prior authorization forward when it is stalling.
Ask your doctor's office for the prior authorization tracking number. Every submitted prior authorization has a reference number. With that number, you can call your insurer directly to check the status and find out whether anything is outstanding.
Follow up proactively. If your prior authorization has been pending for more than five business days, it is reasonable to call your insurer and ask for a status update. Ask specifically whether any additional documentation has been requested and not yet received.
Ask about a peer-to-peer review. If a prior authorization is denied or stalling, your physician can request a peer-to-peer conversation with the insurer's medical reviewer. This is often the fastest path to resolution.
Check whether your state has prior authorization reform laws. Many states have passed legislation requiring faster prior authorization turnaround times, gold carding exemptions for physicians with high approval rates, and transparency about denial rates. These laws vary significantly by state and plan type.
Keep a written record. If you are managing a complex prior authorization situation, keep a log of every call, submission, and response with dates. This record is essential if you need to escalate to a formal appeal or file a complaint with your state insurance commissioner.
What This Means for You
Prior authorization delays are not a personal failing of your doctor or a sign that your medication is inappropriate. They are a structural feature of the current insurance system, and they affect millions of people. Understanding what is happening and how to help move the process forward can meaningfully reduce how long you wait for the care you need.
Ellen can help you understand where your authorization stands and what steps you can take to help move it forward. Start here →
Frequently Asked Questions
How long can an insurance company take to process a prior authorization?
Federal regulations require Medicare Advantage plans to respond to standard prior authorization requests within seven calendar days and urgent requests within 72 hours. The Improving Seniors' Timely Access to Care Act of 2022 established additional electronic prior authorization requirements for Medicare Advantage.⁴ State laws governing commercial plans vary, with many requiring decisions within 14 calendar days for standard requests and 72 hours for urgent ones.
What is an expedited or urgent prior authorization?
An expedited prior authorization applies when your doctor certifies that waiting for a standard review timeline would seriously jeopardize your health or life. In these cases, insurers are required to respond within 72 hours (or faster under some state laws). Your physician must explicitly request expedited review and document the clinical urgency.
Can a denied prior authorization be reversed?
Yes. Prior authorization denials can be reversed through peer-to-peer review, formal internal appeal, or external review. The success rate for appeals is meaningful: studies suggest that a significant proportion of denied prior authorizations that are formally appealed are ultimately approved.⁵
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