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How Can Doctors Manage Urgent Cases When Prior Authorization Is Pending?

Prior authorization (PA) has become a common step in healthcare, especially in the United States. Insurance companies require PA before certain tests, treatments, procedures, or medications can be given to patients. The aim is to control costs and ensure medical necessity, but the process often creates delays.

For doctors, the biggest challenge arises when they face urgent or time-sensitive cases. When a patient’s health is at risk, waiting for insurance approval can compromise care. So, how can physicians manage these situations while still following insurance rules?

Understanding the Challenge

In urgent cases, such as a patient needing emergency imaging, life-saving medication, or immediate surgery, waiting hours—or even days—for prior authorization can cause:

• Delayed treatment that worsens the patient’s condition.

• Increased stress for both patients and providers.

• Administrative burden on medical staff who must chase approvals while treating emergencies.

Strategies for Doctors in Managing Urgent Cases

1. Use the “Urgent/Expedited” Authorization Process

Most insurance companies have a faster review process for cases marked as urgent. Doctors can request expedited PA, which usually requires the insurer to respond within 24 hours. While not always immediate, it’s faster than the standard timeline.

2. Document Medical Necessity Clearly

Strong documentation helps support urgency. Physicians should record symptoms, risk factors, and why immediate intervention is needed. For example, noting “risk of permanent organ damage” or “life-threatening complication if delayed” can speed insurer approval.

3. Provide Treatment First in Emergencies

In true emergencies, doctors are ethically and legally required to provide stabilizing treatment. Under EMTALA (Emergency Medical Treatment and Labor Act) in the U.S., hospitals cannot delay emergency care to wait for insurance approval. After stabilization, the hospital can submit the prior authorization or appeal for coverage.

4. Use Peer-to-Peer Reviews

If an authorization request is initially denied or delayed, doctors can request a peer-to-peer conversation with the insurer’s medical director. This direct communication often helps explain urgency better than paperwork.

5. Leverage Hospital Case Management Teams

Many hospitals have case managers or utilization review teams that specialize in handling insurance approvals. Doctors can work with them to push through urgent PAs while they focus on patient care.

6. Maintain Pre-Approved Pathways for Common Emergencies

Some health systems set up standing approvals or pre-negotiated agreements with insurers for high-risk, frequent emergencies (like heart attacks or strokes). These allow physicians to act quickly without waiting for PA.

7. Appeal Concurrently

If care must proceed without authorization, the provider can still submit an appeal while treatment is ongoing. This helps reduce the chance of denied reimbursement later.

8. Educate Patients About Insurance Barriers

Sometimes patients think doctors are “delaying care” when in fact it’s the insurer’s process. Explaining the reason for delays and the steps being taken can build trust and reduce frustration.

Balancing Patient Care and Insurance Requirements

Doctors must constantly balance two responsibilities:

• Providing timely, life-saving care to the patient.

• Ensuring insurance compliance to avoid financial risks for the hospital or patient.

The best approach is to act first in true emergencies, while simultaneously pushing for expedited authorizations and keeping thorough documentation.

Key Takeaways

• Prior authorization delays can put urgent patients at risk.

• Doctors should use expedited requests, clear documentation, and peer-to-peer reviews.

• Emergency care should never be delayed for insurance approval.

• Hospital case managers and utilization review staff can support physicians.

• Communication with patients is important to maintain trust during delays.

What Did We Learn?

Prior authorization is meant to control costs, but in urgent cases, it often becomes a barrier to care. Doctors can manage these situations by acting immediately in emergencies, requesting expedited approvals, and leveraging hospital support systems. While the insurance process may remain complex, patient safety should always come first.

What People Are Asking?

1. What if prior authorization is denied after urgent care is given?
The hospital can appeal the denial with strong documentation showing the care was medically necessary.

2. Can doctors give treatment without PA in emergencies?
Yes, under EMTALA, emergency care cannot be delayed for insurance approval.

3. How long does an expedited PA usually take?
Most insurers respond within 24 hours, though timelines may vary.

4. Who helps doctors with urgent PA requests in hospitals?
Case managers and utilization review staff usually handle insurance approvals.

5. Can prior authorization be waived for urgent cases?
In some situations, insurers may waive PA requirements if the urgency is well documented.

Disclaimer

For informational purposes only; not applicable to specific situations.

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