Obtaining Prior Authorizations for Medication: Common Hurdles and How to Overcome Them

Prior authorization (PA) is a requirement set by insurance providers that mandates healthcare professionals to obtain approval before prescribing certain medications to patients.

Although the goal is to control medical costs and ensure that patients receive the proper care, PA often results in major roadblocks for patients and healthcare professionals. PA adds administrative complexity for healthcare professionals, requiring time-consuming paperwork and ongoing coordination with insurers. 

For Patients, delays in drug approvals can cause treatment interruptions, worsening symptoms, and frustration.

This article explores common PA process roadblocks and provides practical solutions to speed up approvals, reduce denials, and improve patient access to essential medications. 

Why is Prior Authorization Needed?

The purpose is to ensure that treatments are medically necessary, cost-effective, and align with formulary guidelines. However, the process often introduces delays, increases administrative burdens, and disrupts timely access to essential medications.

What is the Impact on Patient Care? 

Prior authorization can greatly impact patient results, especially for patients with long-term medical disorders requiring ongoing pharmaceutical care.

The above chart shows that 94% of physicians report treatment delays due to prior authorization, contributing to 80% of patient non-adherence and 33% of adverse outcomes.

• Delayed treatment initiation: Delays in starting treatment might cause symptoms to worsen as patients wait days or weeks for approval.
• Increased risk of non-adherence: Long wait periods or coverage denials cause some patients to stop their treatment.
• Problems with managing chronic diseases: Rheumatoid arthritis, diabetes, and high blood pressure all need constant attention, and skipping treatment can have serious consequences.
• Increased healthcare costs: Patients may require hospital stays or ER visits due to delayed medicine, which raises the total cost of healthcare.
• Physician workload strain: Physicians take time from patient care to spend hours on paperwork and resubmissions.

These challenges make it clear why prior authorization remains one of the biggest roadblocks in healthcare workflows. Several obstacles, including burdensome documentation requirements and communication gaps, cause delays and denials. 

The first step in developing a more effective approval process involves understanding these challenges.

Common Hurdles in the Prior Authorization Process

Navigating prior authorization is not a smooth process. It requires thorough paperwork, coordination from multiple stakeholders, and compliance with various insurance regulations. Even when all requirements are met, approval can be delayed or denied due to administrative bottlenecks. 

These obstacles not only put a strain on medical professionals like you but also make it difficult for patients to obtain necessary prescription drugs. 

1. Complex and Inconsistent Approval Procedures

There is no standardization in the prior authorization process. It is challenging for physicians to stay current with the requirements, documents, and submission procedures that vary for each insurer. Even minor discrepancies, such as missing paperwork or an incorrect code, can result in immediate denials, forcing physicians to restart the process.

2. Increased Administrative Burden on Healthcare Providers

Managing prior authorization requests consumes a significant amount of time and resources. Research shows that physicians and their staff handle prior authorizations for an average of 12 hours every week. This time could be better utilized for patient care rather than navigating insurance red tape. 

Burnout among practitioners and inefficiencies in workflow are increased by the manual process of submitting requests, monitoring approvals, and managing denials. 

3. Delays and Disruptions in Patient Care

Prior authorization limitations frequently cause patients to experience unexpected delays in receiving prescription drugs. This may result in:

• Interrupted treatment plans: Patients may be forced to skip necessary medications due to approval delays.
• Higher risk of non-adherence: Patients may stop receiving therapy if they are refused coverage or have to wait a long time.
• Increased hospitalizations: Delays in medication can worsen long-term illnesses, resulting in more frequent ER visits and higher medical expenses.
• Stress and confusion: Patients may feel more frustrated and anxious if they don't understand why their medication needs additional approval.

4. High Rate of Denials and Appeals

Prior authorization requests are often rejected, even when followed by the correct procedures. The most common reasons include:

• Limitations on cost management: Even in cases where a prescription drug is clinically required, insurers may insist on less expensive options.
• Medical necessity disputes: Requests may be denied if documentation does not sufficiently justify the treatment.
• Administrative errors: Automatic rejections may result from incomplete paperwork, incorrect codes, or submission to the wrong payer.

These challenges often lead to one of the most frustrating outcomes—denials. Prior authorization requests may be denied despite following all the required procedures because of insurer-specific policy, cost constraints, or insufficient paperwork. You may increase approval rates by being proactive and knowing the main causes of these denials. 

Reasons for Prior Authorization Denials

A PA denial can derail treatment plans, requiring time-consuming appeals and resubmissions. Awareness of the main causes of denials enables you to take preventive measures.

• Cost Management Factors: Insurance companies frequently reject costly medications for lower-cost alternatives. Insurers may object even if a prescription medication is therapeutically superior unless you can offer compelling proof.
• Medical Necessity Concerns: Insurers may deny requests based on a lack of proven medical necessity if clinical notes lack sufficient details. This is particularly common for newer medications or off-label uses.
• Administrative Errors: Instant denials may result from incomplete paperwork, missing or inaccurate codes, or submission to the wrong payer. 
• Insurance Policy Limitations: Certain medications may not be covered due to formulary restrictions. In certain situations, obtaining approval might require an appeal or a request for a formulary exception.

Proactively addressing these problems can lower denials, but manual PA procedures are still ineffective. This is where electronic prior authorization (ePA) offers a significant advantage.

Utilizing Electronic Prior Authorization (ePA)

Electronic prior authorization (ePA) and other technology-driven alternatives are revolutionizing how healthcare providers handle approvals. By digitizing the PA process, you can decrease human errors and speed up approval timeframes.

The above chart shows that adopting electronic prior authorization (ePA) reduces approval time from 14 days (manual) to just 3 days, streamlining the process significantly.

• Benefits of ePA: Research indicates that ePA greatly increases workflow efficiency by cutting approval delays by 70%. By removing frequent errors, automated data entry increases first-pass approval rates.
• Cost and Error Reduction: Switching from manual to electronic PA can reduce claim denials and administrative expenses. With seamless insurer integration, ePA minimizes the likelihood of lost or incomplete paperwork.
• Proving Medical Necessity with ePA: ePA systems enable physicians to include clinical documentation, guaranteeing insurers are provided with all relevant information upfront. This increases approval rates, especially for costly medications.
• Benefits of Integration: Modern solutions like SPRY's physical therapy management software integrate ePA within the EMR, eliminating the need for separate submission portals. Insurers, pharmacies, and physicians may communicate more effectively, and it eliminates disruptions.

Even though ePA greatly enhances the PA process, obtaining approvals requires a strategic approach. Optimizing documentation, effective communication, and proactive planning can improve success rates. 

Strategies for Successful Prior Authorization

Using a strategic approach is necessary to navigate PA effectively. You can expedite approvals by focusing on proactive documentation and clear communication.

1. Effective Communication with Healthcare Professionals: Motivate patients to continue interacting with their treatment team. Patients can follow up with insurers and prevent needless delays if they know PA rules.
2. Adhering to Submission Guidelines: Each insurer has specific requirements, from pre-authorization codes to supporting medical documentation. Verifying accuracy at the beginning speeds up approvals and minimizes rework.
3. Gathering Supporting Documentation: The reason for approval is strengthened by offering thorough clinical evidence, such as lab results, prior treatment failures, and doctor's notes.

In some cases, denials are unavoidable despite these tactics. It is essential to know how to deal with them effectively. 

Overcoming Denials and Improving Approval Rates

Denials can be a significant setback, but they're not the end of the road. You can resubmit requests and strengthen your case for future approvals using the appropriate tactics and resources. Here are a few key approaches to consider:

1. Appealing Denials: If you receive a denial, always request a detailed explanation from the insurer. A successful appeal can often result from a simple change, such as providing missing evidence or elaborating on medical needs.
2. Understanding the Appeals Process: Appeals can take multiple forms, from internal insurer reviews to independent medical assessments. Knowing the specific steps and deadlines helps you present a more compelling case and speed up the resolution.
3. Case Studies & Success Stories: By implementing automated electronic PA systems, numerous healthcare institutions have significantly decreased denial rates.

 Platforms like SPRY allow physicians to focus on patient care rather than paperwork by boasting a >98% claim approval rate, a 40% reduction in accounts receivable days, and a 30–40% reduction in note-creation time.

SPRY PT’s Success story with Excel Therapy 

Numerous healthcare organizations have benefited from SPRY's advanced automation capabilities, which have helped them reduce denials, overcome prior authorization issues, and increase operational efficiency. A prime example of this transformation can be seen in the case of Excel Therapy.

About Excel Therapy: Excel Therapy is a physical therapy clinic in Panama City, Florida.

Problem Faced: They struggled with an outdated system, leading to billing errors, slow data migration, and scheduling delays.

Solution Offered by Spry: SPRY implemented a customized platform, completing the transition in just two days and streamlining operations.

Results:

• $50,000 revenue increase in the first year.
• Faster 24-hour claims processing.
• 100% uptime and uninterrupted patient scheduling.
• Reduced overall costs and enhanced billing accuracy.

Want to know more about Spry's success stories? Click here. 

With these measures, you can effectively navigate the challenges of prior authorization denials. You may greatly increase your approval rates and preserve more efficient operations by enhancing documentation, keeping up with appeals procedures, and utilizing innovative tools.

Optimizing Process Timing and Urgent Needs

Timing plays a crucial role in the success of prior authorization requests. Treatment disruptions, frustrated patients, and additional administrative burdens are frequently the results of delays. You may guarantee quicker approvals and preserve continuity of service by carefully controlling submission deadlines and utilizing expedited procedures.

1. Submit Requests Early to Meet Deadlines

Initiating PA requests well ahead of deadlines reduces the risk of last-minute scrambling. Being proactive and keeping a close eye on deadlines allows insurers enough time to examine your proposals. This helps maintain treatment timeliness and reduces unexpected delays.

2. Streamline Urgent Approvals

When dealing with critical medications, you can often utilize insurers' expedited pathways for faster decisions. Many urgent requests can be accepted in less than a day if the proper paperwork is submitted and specific emergency procedures are followed. This method guarantees that patients get the treatments they require without unnecessary holdups.

By refining your timing strategies and addressing urgent needs promptly, you pave the way for smoother PA approvals. In the final section, we'll recap the key takeaways and actionable steps to improve the process. 

Conclusion

Prior authorization is a complex yet essential step in ensuring proper medication use. You may greatly reduce delays, increase approval rates, and improve patient outcomes by being aware of common obstacles, enhancing documentation, implementing electronic PA systems, and making advance plans.

SPRY's advanced solutions streamline the PA process by integrating electronic approvals into the clinic's workflow. With 40% reduced accounts receivable days, 30–40% less time spent creating notes, and over 98% claim approval rates, SPRY enables healthcare practitioners to save time and concentrate on patient care.

Start optimizing your prior authorization process today with SPRY's comprehensive platform.