Prior authorization is one of the most universally frustrating aspects of modern healthcare. For patients, it means delays in getting care they need. For practices, it means hours of administrative work for every single authorization request — time that pulls staff away from patient care and generates no revenue.

According to the American Medical Association's 2024 Prior Authorization Physician Survey, physicians and their staff spend an average of 14 hours per week — nearly two full business days — completing prior authorization requests. And 94% of physicians report that prior auth delays negatively impact patient care.

What Is Prior Authorization?

Prior authorization (also called pre-authorization, pre-approval, or prior approval) is a requirement from a health insurance company that a provider must obtain approval before delivering a specific service, procedure, medication, or equipment. If the authorization is not obtained — or if the service is delivered before approval is confirmed — the claim will almost certainly be denied, and the practice typically cannot bill the patient for the balance.

Which Services Typically Require Prior Authorization?

• Elective and non-emergency surgeries and procedures
• Advanced diagnostic imaging — MRI, CT scans, PET scans, nuclear medicine
• Specialist referrals (required by HMO plans, many Medicare Advantage plans)
• Inpatient hospital admissions (non-emergency)
• High-cost specialty medications and biologics
• Durable medical equipment (DME) above a certain cost threshold
• Physical, occupational, and speech therapy beyond the initial evaluation
• Mental health services beyond initial assessment sessions
• Home health services
• Skilled nursing facility admissions

Why Prior Authorization Requests Get Denied

7 Strategies to Speed Up Prior Authorization Approvals

• Use electronic prior authorization (ePA) whenever possible — electronic submissions are processed 3–5x faster than fax or phone requests. Most major payers now support ePA through their portals or via clearinghouse connections.
• Build a payer-specific auth requirement library — document the specific clinical criteria, required documentation, and submission processes for your most frequently billed services across your top 10 payers.
• Verify eligibility and auth requirements simultaneously — make auth verification part of your standard eligibility check, performed 48–72 hours before every appointment.
• Attach complete clinical documentation on the first submission — include physician notes, relevant labs, imaging results, and documentation of prior treatments. Incomplete submissions are the leading cause of delays.
• Request peer-to-peer reviews proactively — when you anticipate a complex case may be denied, proactively request a peer-to-peer review with the payer's medical director before the denial is issued.
• Track all open authorizations in a dedicated system — never rely on staff memory or paper logs. A dedicated auth tracking tool prevents expired authorizations, missed follow-ups, and claims billed without valid auth.
• Appeal every denial immediately — 93% of prior auth denials that are appealed are eventually overturned. Do not accept the first denial as final.

What to Do When a Prior Auth Is Denied

A prior authorization denial is not the end of the road — it is the beginning of the appeal process. Here is the standard escalation path:

1. Request the specific denial reason in writing from the payer
2. Review the denial reason against your clinical documentation
3. Gather any additional supporting documentation (specialist letters, updated labs, imaging)
4. Submit a formal written appeal with additional clinical justification
5. Request a peer-to-peer review between the treating physician and the payer's medical director
6. If still denied, file an external independent review through your state's insurance commissioner
7. For Medicare and Medicaid, escalate through the formal appeals process (redetermination, reconsideration, ALJ hearing)

How HNA Manages Prior Authorization

Healthcare Network Associates manages the complete prior authorization workflow as part of our RCM service. Our dedicated auth team submits requests electronically, monitors approval status, follows up on pending cases proactively, and appeals denials within 24 hours — saving most practices 10–15 hours of staff time every single week.