Prior Authorization Delays Are Driving Patients Away From Providers

Almost 80% of physicians surveyed by the AMA say patients are skipping care because of delays in prior authorizations.

Prior authorizations are a consistent pain point in revenue cycle operations, and a new survey shows just how detrimental they are for patients.

According to the American Medical Association’s annual prior authorization survey, 78% of physicians said issues with prior authorization resulted in patients forgoing care.

The survey of 1,000 practicing physicians offers some significant insights to the negative impact of prior authorization on the patient’s care experience:

• 94% said prior authorization “always, often or sometimes” delayed a patient’s access to necessary care.
• 19% said prior authorization resulted in an event leading to a patient being hospitalized.
• 13% said prior authorization resulted in an event leading to a life-threatening event or requiring intervention to prevent permanent damage.
• 7% said prior authorization resulted in an event leading to a patient’s disability, permanent bodily damage, congenital anomaly, birth defect or death.

Prior authorizations are a significant problem for providers as well, with many having to rely on multiple staff to work on them, according to a 2023 survey by the Medical Group Management Association.

Another report by the Kaiser Family Foundation found that 6% of the 35 million prior authorization requests submitted to Medicare Advantage in 2021 were denied. Of those denials, only 11% were appealed, and of that group, 82% were fully or partially overturned.

Some health systems, like University Health KC, have turned to tech solutions to manage prior authorizations, and seen some results.

“Within about two months of kicking off implementation, [the program] started going to payer websites and logging requests for prior authorizations by taking that information out of our EMR,” Seth Katz, vice president of revenue cycle and HIM, previously told HealthLeaders.

In January, the Centers for Medicare and Medicaid Services finalized the Interoperability and Prior Authorization Rule, setting requirements to streamline the process for Medicare Advantage, the Children’s Health Insurance Plan (CHIP), and Medicaid managed care plans, among others.

The rule adds provisions to increase data sharing, in turn, reducing the administrative burden on providers, enabling them to spend more time providing care. For example, as part of one requirement for the rule, payers must send prior authorization decisions for expedited requests within 72 hours. For standard requests, decisions must be sent within seven calendar days.

The rule is expected to result in $15 billion in savings over the next 10 years.