Consequences of Prior Authorization Delays

Impact on Patient Care and Outcomes

Delays in prior authorization can limit patient access to appropriate imaging procedures and medical interventions, potentially compromising quality of care 1
Delays in diagnosis resulting from prior authorization requirements can direct patients to higher-cost diagnostic approaches through layered testing 1
For time-sensitive procedures, delays beyond 8 weeks may negatively impact patient-important outcomes 2

Prior authorization processes require significant administrative time from providers, taking valuable time away from patient care activities 3, 4
Healthcare providers often need to dedicate non-physician staff members solely to navigate the considerable time required for prior authorization processes 5

In cardiac care, prior authorization delays may compromise time-sensitive interventions for conditions like ST-elevation myocardial infarction (STEMI), where timely treatment is critical 6
For gastrointestinal procedures, delays beyond 8 weeks for time-sensitive indications may negatively impact patient outcomes 2

Prior authorization methodologies vary greatly among payers and regions of the country, creating inconsistency in care delivery 1
Prior authorization frequently relies on proprietary algorithms that may be inconsistent with published literature and clinical guidelines 1

Healthcare organizations should establish dedicated teams to navigate the prior authorization process, particularly for complex or time-sensitive cases 5
Payors and providers should consider alternative coding systems for procedures requiring prior authorization to better account for the administrative burden 3
Managed care organizations should minimize burdens placed on providers and patients when administering prior authorization requirements 4
Streamlining overlapping requirements between prior authorization and other administrative processes would benefit both providers and payors 3

The clinical team, including providers, case management, and pharmacists, is typically responsible for completing prior authorizations to ensure patients receive prescribed treatments 7
Pharmacists can play a key role in navigating insurance coverage and prior authorization requirements, and may initiate and complete prior authorizations on behalf of the clinical team 7

Federal mental health parity laws extend to nonquantitative limits, including prior authorization, requiring that prior authorization requirements for mental health and substance use disorder medications be no more burdensome than for medical/surgical conditions 8, 9
Violations of parity laws persist, with prior authorizations often required for generic medications for substance use disorders when generics for chronic physical diseases are not 9

Sending prescriptions to the dispensing pharmacy 1-2 days prior to discharge can help determine if prior authorization is required and allow time for completion 7
Requesting "expedited review" of prior authorizations when clinically appropriate can help minimize treatment delays, with Medicare requiring response within 24 hours for expedited reviews 7
Failing to initiate the prior authorization process early enough can lead to treatment delays, and assuming prior authorization approval will transfer automatically when patients change pharmacies can also cause issues 7
Accepting initial denials without appeal can result in delayed treatment, as 82% of initially denied prior authorizations are eventually approved upon resubmission with clinical documentation 7