Every year, millions of patients in the U.S. wait days-or even weeks-for a simple treatment to be approved. Not because it’s unsafe. Not because it won’t work. But because a form hasn’t been signed, a fax hasn’t gone through, or a system glitch blocked the request. This isn’t bureaucracy for the sake of bureaucracy. It’s a system that’s supposed to protect patients, but too often, it puts them at risk.
What Prior Authorization Actually Does (and Doesn’t Do)
Prior authorization is a gatekeeping step used by insurance companies to approve certain medications, tests, or procedures before they’re given. The idea is simple: make sure the treatment is medically necessary and cost-effective. But in practice, it’s become a bottleneck that delays care for people who need it most. For example, if your doctor prescribes a specialty drug for multiple sclerosis that costs $12,000 a month, your insurer will likely require prior authorization. That means your provider must submit clinical notes, lab results, and proof that cheaper alternatives failed. Even if your doctor has treated you for years with the same medication, you might still be stuck waiting. The problem isn’t the concept-it’s the execution. A 2024 study from the American Medical Association found that 93% of physicians say prior authorization causes delays in care. And those delays aren’t just annoying-they’re dangerous. In cancer care, a delay of 28 days or more has been linked to a 17% higher risk of death. For patients on immunosuppressants after a transplant, even a 72-hour hold can trigger organ rejection.Why the System Is Broken
Most prior authorization requests still rely on outdated tools. As of 2024, nearly 85% of requests are submitted by fax, phone, or paper. That means a doctor’s office spends an average of 16 hours a week just chasing approvals. Staff spend another 14 hours on it. That’s not time spent with patients. That’s time spent playing phone tag with insurance call centers. And it’s not just slow-it’s inconsistent. Medicare Advantage plans require prior authorization for nearly 25% of prescriptions. Medicaid varies wildly by state: the same drug might need authorization in 12% of cases in one state and 89% in another. Commercial insurers approve 60% of specialty drugs only after step therapy-meaning you have to try and fail on cheaper drugs first, even if your doctor knows they won’t work for you. The worst part? Denials are common and often arbitrary. One patient in California waited 11 days for insulin pump approval. By the time it came through, they were hospitalized with diabetic ketoacidosis. Another patient with epilepsy died after being unable to afford medication during a 3-week authorization delay. These aren’t rare cases. They’re symptoms of a broken system.Who Gets Hurt the Most
It’s not just about delays. It’s about who bears the burden. Patients with chronic conditions-diabetes, cancer, autoimmune diseases-are hit hardest. They need consistent access to medication. A gap of even a few days can lead to hospitalization, complications, or death. Low-income patients are more likely to abandon treatment because they can’t afford to pay out of pocket while waiting. Elderly patients often don’t have the energy or tech skills to navigate insurance portals. Rural patients face longer delays due to fewer providers and slower internet. And it’s not just patients. Doctors are burned out. Nurses are overwhelmed. Pharmacists are stuck in limbo. One survey found that 82% of patients have abandoned a prescribed treatment because of prior authorization hurdles. That’s not patient noncompliance. That’s system failure.
How Providers Can Reduce Treatment Gaps
There are real, practical steps providers can take right now to protect their patients:- Verify benefits at the point of care. Don’t wait until after the visit. Use your EHR to check if a drug or service requires prior authorization before you write the prescription. Practices that do this see a 28% drop in authorization requests.
- Use standardized templates. Instead of rewriting clinical notes for every request, create pre-filled templates for common conditions like rheumatoid arthritis, MS, or depression. This cuts documentation time by 40%.
- Build a dedicated prior auth team. Assign one or two staff members to handle authorizations full-time. They learn the ins and outs of each payer’s rules. Practices with dedicated teams see approval rates rise by 22%.
- Use electronic systems. If your practice still faxes requests, you’re 3 times slower than those using electronic systems. Electronic prior authorization cuts approval time from over 5 days to under 2 days.
- Prepare bridge therapy. For high-risk patients, keep a 7- to 14-day supply of medication on hand. It’s not ideal-practices pay for it out of pocket-but it can be lifesaving. Some states now require insurers to cover bridge therapy.
What Patients Can Do to Protect Themselves
You don’t have to wait passively. Here’s what you can do:- Ask about prior authorization before you leave the office. When your doctor writes a prescription, ask: “Does this need approval from my insurance?” If they say yes, ask them to start the process right away. Patients who do this reduce delays by 63%.
- Call your insurer directly. Don’t wait for your doctor’s office to follow up. Call your plan and ask for the status. Get a reference number. Know the deadline for approval.
- Ask about patient assistance programs. Many drug manufacturers offer free or low-cost medication during authorization delays. Check the manufacturer’s website or ask your pharmacist.
- Know your rights. Federal law requires insurers to respond to urgent requests within 72 hours and non-urgent ones within 14 days. If they miss the deadline, the treatment should be approved automatically.
The Future Is Changing-But Not Fast Enough
There’s good news. The government is finally stepping in. In January 2024, CMS mandated that all Medicare Advantage and Medicaid plans switch to electronic prior authorization by 2026. Real-time approvals will become the standard. The HL7 DaVinci Project’s PDEX standard is now used by 87% of major health systems, allowing providers to check authorization status right in their EHR. AI tools are also emerging. Platforms like Kyruus and Apricus Analytics can predict which requests will be approved or denied before they’re even submitted. One pilot reduced processing time by 60%. But change moves slowly. As of mid-2024, 63% of Medicaid programs still rely on fax machines. Only 41% of physicians say things have improved. And without federal limits on when prior authorization can be required, dangerous delays will keep happening.When Prior Authorization Might Actually Help
Let’s be fair: it’s not all bad. In some cases, prior authorization prevents unnecessary procedures. A patient might be scheduled for an MRI when a simple X-ray would do. A drug might be prescribed when a generic alternative is just as effective. In those cases, the system works. But it shouldn’t be used as a blanket rule for everything. The goal should be to target high-cost, low-value services-not essential, time-sensitive care.What’s Next? Don’t Wait for the System to Fix Itself
The truth is, no policy change, no new app, no AI tool will fully fix this unless providers and patients push back together. If you’re a provider: start using electronic systems. Train your team. Document every delay. Report denials that led to harm. If you’re a patient: ask questions. Follow up. Don’t accept “we’ll get back to you” as an answer. If your treatment is delayed, contact your state’s insurance commissioner. File a complaint. Share your story. Prior authorization was never meant to be a barrier to care. It was meant to ensure care was appropriate. But today, it’s often the reason care doesn’t happen at all. The system is broken. But it’s not hopeless. Change starts with awareness-and action.What is prior authorization and why does it delay my treatment?
Prior authorization is a requirement from your health insurer that your doctor must get approval before prescribing certain medications or ordering specific tests or procedures. It’s meant to ensure treatments are medically necessary and cost-effective. But because most requests are still submitted by fax or phone, and insurers take days to respond, patients often wait weeks for approval-even when the treatment is urgent. This delay can lead to worsening conditions, hospitalization, or even death.
Which treatments commonly require prior authorization?
Specialty drugs costing over $1,000 per month, such as those for cancer, multiple sclerosis, or rheumatoid arthritis, almost always require prior authorization. High-cost imaging like MRIs and CT scans, surgeries, durable medical equipment (like oxygen tanks or insulin pumps), and certain mental health medications also commonly require approval. Medicare Advantage plans require prior authorization for nearly 25% of prescriptions, while commercial insurers require it for up to 60% of specialty drugs.
How long should prior authorization take?
Federal rules require insurers to respond within 72 hours for urgent requests and 14 days for non-urgent ones. In practice, Medicare Advantage plans take an average of 5.3 days, Medicaid takes 7.2 days, and commercial insurers average 4.7 days. But when requests are submitted by fax-still the norm for 85% of cases-delays of a week or more are common. If the deadline passes without a response, the treatment should be approved automatically.
What should I do if my prior authorization is denied?
If your request is denied, your provider should file an appeal. You can also file your own appeal directly with your insurer. Gather all medical records, letters from your doctor explaining why the treatment is necessary, and any evidence of prior treatment failures. Many denials are overturned on appeal. If the appeal is denied, you can request an external review by an independent third party, which is required by law.
Can I get my medication while waiting for approval?
Yes, but it depends. Some drug manufacturers offer free 7- to 14-day samples for patients waiting on approval. Your doctor may also have a small supply on hand for emergencies. Some states now require insurers to cover bridge therapy. If none of these options are available, you can apply for patient assistance programs through the drugmaker’s website or nonprofit organizations like NeedyMeds or the Patient Access Network Foundation.
Is there a law that limits prior authorization?
Yes. The CMS Interoperability and Prior Authorization Rule (CMS-0057-F), finalized in January 2024, requires all Medicare Advantage and Medicaid managed care plans to use electronic prior authorization systems with real-time decision-making by December 2026. Additionally, 32 states have passed laws limiting prior authorization for certain conditions, requiring faster decisions, or banning step therapy for life-threatening illnesses. The AMA’s Prior Authorization Relief Act, introduced in 2024, seeks to create federal standards to prevent prior authorization for stable, chronic conditions.
