Why Do Medical Prior Authorizations Take So Long?
What Is a Prior Authorization?
Prior authorization, sometimes called preauthorization or precertification, is a process used by health insurance companies to determine whether certain medical services, procedures, tests, equipment, or prescription medications meet the requirements for coverage under a health plan.
Not every medical service requires prior authorization. However, higher-cost or more specialized services frequently do.
Examples may include:
MRI and CT scans
Certain surgeries and outpatient procedures
Specialty prescription medications
Physical or occupational therapy
Durable medical equipment
Some injections and infusion treatments
Certain specialty services or treatments
The important thing to understand is that a doctor’s recommendation and an insurance company’s authorization are two separate steps.
Your physician may believe a test or procedure is medically appropriate, but the insurance company may still require documentation before it agrees that the service meets the plan’s coverage requirements.
Why Can the Process Take So Long?
Prior authorization timelines vary by plan and state rules, but there are some common patterns. For non-urgent requests, insurers commonly respond within 5 to 15 calendar days. Some take longer if more info is needed. If the situation is urgent, doctors can often request an expedited review, which is generally decided within 72 hours. And sometimes faster, depending on state law. For medications at the pharmacy, It can be a few days if all the documentation is ready, but step therapy or missing history can stretch it longer. If you hear nothing, say, after a week, it’s reasonable to check whether the request was submitted, ask for the reference number, and call your plan to verify what’s pending.
One of the biggest reasons for delays is that prior authorization involves several different parties.
The process may include the patient, physician, physician’s office staff, hospital or imaging facility, pharmacy, insurance company, and sometimes a third-party company that manages authorizations for the insurer.
Each party may be waiting for information from someone else.
For example, a physician may order an MRI. Before scheduling it, the imaging facility discovers that prior authorization is required. The physician’s office then submits the request to the insurance company.
The insurer may ask for medical records showing that certain treatments were already attempted. The physician’s office must gather and submit those records. The insurance company then reviews them and may request additional information.
What sounds like one simple approval can actually involve numerous separate steps.
Missing Information Can Stop the Process
One of the most common causes of prior authorization delays is incomplete documentation.
An insurance company may require specific information before approving a request, such as previous treatment history, X-rays, laboratory results, therapy notes, medication history, or documentation showing that a less expensive treatment was attempted first.
If something is missing, the request may be placed on hold or returned for additional information.
Unfortunately, the patient may not even realize this has happened.
The doctor’s office may believe it is waiting on the insurance company, while the insurance company may be waiting for additional records from the doctor’s office.
That is why communication can be extremely important.
Medical Necessity and Insurance Guidelines
Another source of frustration is the difference between a doctor’s medical judgment and an insurance company’s coverage guidelines.
Your doctor is treating you as an individual patient. The insurance company, meanwhile, is reviewing the request according to the terms of your health plan and its medical-necessity criteria.
Those two perspectives do not always line up perfectly.
For example, an insurance company may require several weeks of physical therapy before approving an MRI for certain conditions. Your physician may believe an MRI should be performed sooner based on your symptoms.
That disagreement can result in requests for additional documentation, a denial, an appeal, or a physician-to-physician review sometimes called a peer-to-peer review.
Each additional step takes time.
Prescription Drugs Can Have Additional Requirements
Prescription prior authorizations can be especially complicated.
Some health plans use what is known as step therapy. This generally means a patient may be required to try one or more preferred medications before the plan will cover another medication.
The physician may need to document that the preferred medication was ineffective, caused side effects, or was medically inappropriate for the patient.
Specialty medications can involve even more requirements because of their cost and the conditions they are designed to treat.
This doesn’t necessarily mean the medication won’t be covered. It may simply mean additional information must be provided before a coverage determination can be made.
Prior Authorization Is Not Always a Guarantee of Payment
There is another important misconception patients should understand.
Receiving prior authorization does not necessarily guarantee that an insurance company will ultimately pay the entire claim.
Final payment can depend on several factors, including eligibility on the date of service, network status, the specific services actually performed, coding, plan exclusions, deductibles, copayments, coinsurance, and other provisions of the insurance contract.
In other words, authorization is an important step—but it is not always the final step.
What Can Patients Do?
Patients don’t have to simply sit and wait without asking questions.
If a prior authorization seems to be taking an unusually long time, consider asking:
Has the prior authorization actually been submitted?
This is an important distinction. Sometimes patients are told that an authorization is “being worked on,” when the request has not yet been formally submitted to the insurance company.
You can also ask for the authorization or reference number once one is available.
Next, ask whether the insurance company has requested additional information.
If it has, find out exactly what is missing and whether the doctor’s office has submitted it.
You may also want to contact your insurance company’s member services department directly. Ask whether the request is pending, approved, denied, or waiting for additional medical documentation.
If the request has been denied, ask about your appeal rights and whether an expedited review is available when medically appropriate.
Most importantly, if your health is worsening while you are waiting, contact your healthcare provider. A medical professional—not an insurance agent or customer service representative—should advise you about what to do when symptoms change or become urgent.
Your Insurance Agent Can Help You Understand the Process
An insurance agent generally cannot make a medical determination or force an insurance company to approve a procedure. However, a knowledgeable agent can often help you understand your plan, identify the correct insurance department to contact, and explain some of the terminology being used.
Sometimes simply knowing who is waiting on whom can help move the conversation forward.
Prior authorization is one of the more frustrating realities of today’s healthcare system. It was designed in part to help ensure that covered medical services are appropriate under a health plan’s guidelines and to manage healthcare costs, but the process can create significant administrative burdens for patients and healthcare providers.
When you’re waiting for a medical test, procedure, or medication, even a few days can feel like a very long time.
Understanding the process, asking specific questions, keeping records of conversations, and staying in communication with both your healthcare provider and insurance company can help you become a more informed advocate for your own healthcare.
HealthWise Insurance Group
Your Path to Better Coverage