Where a Prior Authorization Actually Waits
When patients talk about prior authorization, they talk about waiting. When payers talk about it, they talk about turnaround time. Those are two different clocks, and much of the improvement work in an authorization process sits in the gap between them.
I first saw this from the inside. As a population health program project manager at a managed care medical group, a good part of my work involved service referrals and insurance authorizations. Delays can occur at several points along the way, including before a request is ever submitted, where the time is easy to overlook.
The clock the patient is on
The CMS Interoperability and Prior Authorization Final Rule sets firm deadlines for Medicare Advantage plans and Medicaid and CHIP programs, including managed care, beginning January 1, 2026: 72 hours for expedited requests, seven calendar days for standard ones, and a specific reason whenever a request is denied. I think that is meaningful progress. It is worth remembering, though, that the patient’s clock started the day the physician said the service was needed, which can be well before a complete request reaches the plan.
In between, an order can sit in an inbox. Coverage may not have been verified yet. A clinical note may still need a signature. The request may move between two departments without either one clearly owning it. Each of these adds a day or several, and none of that time appears in a payer turnaround report.
For that reason, the most useful first measure is the whole path, from the clinical decision to the final outcome. A practice that can only report the payer’s number has no way to see its own share of the delay.
Following a single request
One useful approach is to pick a small number of requests and trace each one from start to finish, asking the same questions at every stop.
The first is whether there was an intake standard and whether the request met it. A request that leaves intake without coverage verification, a diagnosis, supporting documentation, and the payer’s specific requirements is very likely to come back. Rework of this kind is a common source of delay, and it is the one a practice has the most control over.
The second is who owned the request at that moment. The answer should be a person, with a status and a next action, and a department name does not answer the question. When ownership lives in someone’s memory or in an email thread, the request stops moving on the day that person is out of the office.
It also helps to ask how the team defines urgent. If every late request gets marked urgent, the requests that truly are urgent lose their priority. A written standard for expedited handling, along with a way to escalate without submitting a duplicate, protects them.
Then comes the documentation itself. The strongest submissions explain how the service relates to the condition, what has already been tried, and how the request meets the coverage criteria, in a form a reviewer can follow quickly. Adding pages rarely helps and often slows the review down.
Finally, look at what happened after the decision. An approval should lead to scheduling the same day. A denial should lead to a specific response, which may be supplying a missing piece or filing an appeal where one is warranted, and in every case recording the reason. Now that payers are required to state their reasons, a denial log has become one of the most useful sources of operational information a practice has. It is also one of the most underused.
What the denial log shows
Once a denial log is sorted by reason, the denials tend to stop looking random. One service line may be sending incomplete records. One payer may account for most of the confusion about status. One note template may never address medical necessity directly. These are process problems with practical fixes, and they are seldom the fault of any one staff member.
Technology will help, and the CMS rule is moving the industry toward electronic exchange. I would still encourage any practice to map its current path before automating it, because a fragmented process that has been digitized is still fragmented.
The authorization teams I most respect spend very little time chasing overdue requests. They have put their effort into complete intake, clear ownership, and reading their denials. Their patients mostly never know about that work. What the patient notices is that the care they were told they needed began this month instead of next.
Sources
- CMS: 2024 Interoperability and Prior Authorization Final Rule
- CMS: Rule to Expand Access to Health Information and Improve the Prior Authorization Process
About the author
Sherry Sayari, MPH, is an Operational Standards Evaluator who has led population health, community outreach, and social services programs. More on the About page.
