From a technical standpoint, prior authorization is a process that ensures certain medical treatments and services meet a patient’s health plan requirements before they are delivered, preventing the back-and-forth that can happen when a healthcare service is delivered and billed but isn’t actually covered. However, the process itself can take a significant amount of administrative time.
According to a 2024 survey by the American Medical Association, providers and practice staff spend an average of 13 hours every week completing prior authorizations. That is nearly two full working days that are spent on just one administrative process.
But why exactly is prior authorization time-consuming? More importantly, what should your practice do when a patient’s insurance requires one?
How Does Prior Authorization Work?
Complying with prior authorization requirements varies based on the patient’s health plan and the medical service they are seeking. However, the process usually starts by identifying whether or not a patient’s insurance needs approval before they can start their healthcare journey.
Once you confirm that approval is necessary, your team then needs to gather the necessary information so you can submit it to the health plan and wait for a decision. Should they ask for additional documentation or information, you will need to provide it before proceeding with the patient’s care.
Because of this, prior authorization isn’t always finished once the initial request has been submitted. Your team may still need to monitor it, communicate with the insurer, and provide additional information until a decision is made.
What Happens if Prior Authorization is Denied?
A denied prior authorization doesn’t necessarily mean your patient has run out of options. Instead, your first step should be determining why the health plan denied the request.
For example, the insurer may simply be looking for additional clinical documentation, want another treatment to be tried first, or the requested service may not meet the health plan’s coverage criteria. Depending on why the request was denied and the patient’s plan, you may be able to request reconsideration or file an appeal so that the patient can get the treatment they need.
Since each health plan can have different requirements and appeal procedures, make sure your team follows the instructions provided with the denial.
How Can Your Practice Manage Prior Authorizations More Efficiently?
While you can’t control the requirements set by a patient’s health plan, you can make the process easier to manage within your practice, and this starts with a consistent workflow.
Given the critical part your practice and your staff play in getting prior authorizations approved, you should establish a process for how your team verifies and organizes the requirements provided by your patients, as well as how these are to be submitted.
Apart from the pre-submission processes, you should also make sure someone is responsible for keeping track of each submission so your practice won’t overlook any potential follow-ups and additional documentation requests. It can also help to keep frequently used payer information and requirements organized, so your team will know where to look when starting a new request.
If prior authorization is already taking a significant amount of your team’s time, you may also want to assign some of its administrative responsibilities to a dedicated employee. This can be an in-person staff member or a healthcare-trained virtual assistant, depending on which parts of the process you need help managing.
For example, My Mountain Mover can help you find a medical virtual assistant (VA) who can support your practice with administrative responsibilities related to prior authorization, along with other time-consuming healthcare tasks. This can give your in-house team additional support without requiring every administrative responsibility to stay with someone inside your practice.
Whichever approach you choose, the goal is to make sure every request has someone responsible for following it from start to finish. After all, submitting a prior authorization is only one part of the process. Your patient still needs an answer before they can determine what happens next.
Get More Administrative Support for Your Practice
Prior authorization may be a routine part of working with health plans, but managing requests shouldn’t have to take time away from the rest of your team’s responsibilities.
My Mountain Mover can help you find a healthcare-trained virtual assistant who can support prior authorization and other administrative tasks for your practice. Schedule a free consultation today to find your ideal VA.
Frequently Asked Questions
How long does prior authorization take?
There is no single turnaround time for every prior authorization. How long a decision takes can depend on the patient’s health plan, the type of request, whether it is urgent, and whether the insurer needs additional information from your practice.
Who is responsible for obtaining prior authorization?
The responsibility can vary depending on the service and how your practice divides its administrative work. Prior authorization requests often require information from the ordering provider, but administrative staff can help prepare, submit, and track requests.
Is prior authorization the same as a referral?
No. Prior authorization involves getting approval from a patient’s health plan for certain treatments, medications, or services. A referral generally involves one healthcare provider directing a patient to another provider or specialist. Depending on the patient’s plan and the care they need, both may be required.
