Managing Prior Authorizations: How to Prevent Dangerous Treatment Delays

Why Prior Authorization Can Kill

Imagine you’re prescribed a life-saving medication. Your doctor signs off. You’re ready to fill it. Then you’re told: you need approval first. That approval could take days. Or weeks. And if it’s delayed, your condition could worsen - fast.

This isn’t hypothetical. In 2023, a diabetic patient in Texas went 11 days without insulin because her insurance wouldn’t approve her pump. She ended up in the ER with diabetic ketoacidosis. A transplant patient in Florida waited 18 days for an immunosuppressant. He developed organ rejection. A man with epilepsy died after his family couldn’t afford his meds while waiting for approval. These aren’t rare cases. They’re symptoms of a broken system.

Prior authorization was meant to stop unnecessary treatments. Instead, it’s now a major cause of dangerous treatment gaps. Over 35 million Medicare Advantage patients face this hurdle every year. For specialty drugs - the kind that cost over $1,000 a month - nearly 60% of commercial plans require prior approval. And 85% of those requests still go through fax machines, phone calls, or paper forms. That’s not efficiency. That’s chaos.

How Prior Authorization Actually Works (And Why It’s So Slow)

Prior authorization isn’t a single rule. It’s a patchwork of policies that vary wildly by insurer, state, and even the drug you’re taking.

Medicare Part A and B rarely require it. But Medicare Advantage? They demand it for 83% of specialty drugs. Medicaid varies by state - one drug might need approval in 12% of cases in one state, and 89% in another. Commercial insurers use it for 20% of generic drugs, 30% of brand-name meds, and nearly two-thirds of high-cost specialty treatments.

Here’s how it breaks down:

• You get a prescription
• Your doctor’s office calls or faxes the insurer with clinical notes, diagnosis codes, and proof the drug is necessary
• The insurer reviews it - often manually - and either approves, denies, or asks for more paperwork
• You wait. And wait. And wait

The average approval time? Four to seven business days. For urgent cases? The law says 72 hours. But in practice, many patients wait longer. And if your case is denied? You start the appeal process. That can add another two to four weeks.

Doctors and staff spend an average of 16 hours a week just managing these requests. That’s two full workdays. And for what? To delay care that’s already been deemed medically necessary by your doctor.

The Real Cost: Treatment Gaps That Lead to Death

Prior authorization doesn’t just waste time. It kills.

A 2023 JAMA Oncology study found that cancer patients who waited more than 28 days for treatment had a 17% higher risk of death. Why? Because cancer doesn’t pause for paperwork. Neither do seizures, heart failure, or autoimmune flare-ups.

Surveys of 945 physicians show:

• 93% have seen treatment delays because of prior auth
• 91% have seen patients’ health get worse as a result
• 82% have had patients quit treatment entirely because the process was too hard
• 34% have seen serious adverse events - like hospitalizations or deaths - directly tied to delays

And it’s not just about drugs. MRIs, CT scans, surgeries, oxygen tanks - all require approval. One patient needed a wheelchair. The insurer took 19 days to approve it. She fell twice during that time. Broke her hip.

These aren’t edge cases. They’re the norm. And the people hit hardest? Low-income patients, those with chronic illnesses, and older adults. They’re less likely to have the time, energy, or support to fight through bureaucracy.

What’s Being Done? The Slow Push for Change

There’s momentum - but it’s moving at fax speed.

In January 2024, CMS announced a new rule: by December 2026, all Medicare Advantage and Medicaid managed care plans must use electronic prior authorization systems with real-time decision-making. That’s huge. Right now, only 15% of requests are processed electronically. The rest? Fax, phone, mail.

Thirty-two states have passed reform laws since 2021. California now requires emergency authorizations within 24 hours. New York limits approvals to 72 hours for urgent cases. Colorado bans step therapy for mental health drugs.

Technology is helping too. AI tools like Kyruus and Apricus Analytics are cutting approval times by 45-60% in pilot programs. The HL7 DaVinci Project’s PDEX standard - now used by 87% of major health systems - lets doctors check prior auth status right inside their electronic health records. No calls. No faxes. Just a click.

But here’s the catch: 63% of Medicaid programs still use fax machines. And 41% of doctors say things haven’t improved at all.

What You Can Do: A Practical Guide to Avoiding Delays

You can’t fix the system overnight. But you can protect yourself.

For Patients:

1. Ask upfront. When your doctor prescribes a drug, ask: “Does this need prior authorization?” Don’t assume. 63% of delays are avoided when patients ask this at the time of the prescription.
2. Know your plan. Log into your insurer’s website. Look up the drug. See if it’s on formulary. See if prior auth is required. If it’s not clear, call customer service - and take notes.
3. Use patient assistance programs. Many drug makers offer free or low-cost samples for people waiting on approval. Ask your doctor or pharmacist. These aren’t charity - they’re a lifeline.
4. Keep records. Save every email, fax confirmation, phone call log. If you’re denied, you need proof you tried.

For Doctors and Care Teams:

• Use electronic prior auth tools. Practices that switched from fax to digital saw approval times drop from 5.2 days to 1.8 days.
• Build templates. Standardized forms for common drugs cut documentation time by 40%.
• Set up a dedicated prior auth team. One person trained to handle this full-time improves approval rates by 22%.
• Use bridge therapy. For high-risk patients, give a 7-14 day supply of meds while waiting. Yes, it costs you. But it’s cheaper than an ER visit.

The Bottom Line: This Isn’t About Saving Money - It’s About Saving Lives

Prior authorization was sold as a way to control costs. And yes, it reduces spending - by 15-22% on high-cost services. But the cost to patients? It’s measured in missed treatments, hospitalizations, and deaths.

Healthcare isn’t a ledger. It’s human. And when you delay a drug that stops seizures, or an MRI that catches a tumor, you’re not saving money. You’re gambling with lives.

The fix isn’t complicated: go digital. Set time limits. Ban fax machines. Make decisions in real time. Stop treating patients like insurance puzzles.

Until then, if you’re on a chronic medication - or caring for someone who is - don’t wait for the system to change. Start now. Ask the questions. Document everything. Push back. Your life depends on it.

Frequently Asked Questions