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How Prior Authorization Impacts Care, Cost, and Clinical Workflows?

Prior Authorization (PA) also known as pre-authorization or pre-certification is a process required by many health insurance companies to approve specific medications, medical procedures, tests, or durable medical equipment (DME) before they are provided. It’s a method used to ensure treatments are medically necessary and cost-effective.

While Prior Authorization is often viewed as a hurdle, it also plays a role in helping patients access expensive but necessary services and specialty drugs. It may also help avoid unnecessary hospital stays by ensuring the right care is delivered at the right time.

A Tool for Utilization Management

Health insurance payers use Prior Authorization as part of a utilization management strategy to evaluate the clinical necessity and cost implications of certain healthcare services. It helps control healthcare spending and ensures patients receive evidence-based care sometimes guiding them to lower-cost alternatives that offer similar outcomes.

How the Prior Authorization Process Works With Staffingly?

The process typically unfolds in the following steps:

1. Provider Evaluation: A doctor determines the patient needs a specific test, medication, or treatment.

2. Coverage Check: The provider reviews the patient’s insurance plan to confirm if Prior Authorization is needed for the requested service.

3. Policy Review: Because clinical and billing systems aren’t always integrated, providers must manually check insurer-specific PA rules, often via PDF documents or payer websites.

4. Code Matching: If PA is required, the provider must match the appropriate CPT code(s) to the treatment and follow the insurance-specific requirements.

5. Request Submission: The provider completes and submits the PA request form usually via fax, secure email, or online portal along with any clinical documentation.

6. Await Decision: The provider remains in contact with the insurer to receive an approval, denial, request for more information, or alternative recommendation.

7. Include PA Number in Claim: Once approved, the PA number must be referenced when the final claim is submitted to avoid denial.

How Long Does Prior Authorization Take?

The processing time varies. While some routine PAs are approved in 2–5 business days, more complex requests can take several weeks especially when clinical justification or appeals are involved. Some insurance companies offer expedited reviews for urgent cases, which may yield a decision in hours or one business day.

How to Submit a Prior Authorization Request (Step-by-Step)

Because PA rules differ across insurers, here’s a general guide for submitting a request:

Step 1: Confirm Patient Eligibility

Verify the patient’s active insurance coverage and any specific restrictions related to the proposed service.

Step 2: Check if PA Is Required

Review the insurer’s guidelines or formulary to see whether the medication or service requires PA.

Step 3: Gather Forms and Documentation

Download the insurer’s PA request forms and fill out necessary patient and provider information, including supporting clinical data.

Step 4: Submit the Request

Send the completed form and supporting documentation via the insurer’s preferred method typically online, fax, or secure email.

Step 5: Follow Up on the Status

Track the PA request’s progress and respond to any additional documentation requests to avoid unnecessary delays.

What Happens After Submission?

Once the PA is submitted, the insurance provider may:

• Approve the request

• Deny the request

• Request more information

• Recommend trying a more cost-effective treatment first

• Require an appeal if denied

The Administrative Burden of Prior Authorizations

Healthcare professionals report significant challenges navigating the PA process. According to the American Medical Association (AMA):

• Physicians spend an average of 16 hours per week managing PA requests.

• 89% report that PAs cause delays in patient care.

• Many practices are forced to assign dedicated staff to handle PAs, increasing administrative costs without direct revenue benefits.

Reducing the Burden: A Case for Outsourcing

Managing PAs internally can consume valuable clinical and administrative time—especially when requirements constantly change across insurers. Outsourcing Prior Authorization to trained administrative professionals can:

• Ensure up-to-date compliance with payer-specific rules

• Reduce delays due to missing codes or incorrect documentation

• Free up internal staff for patient-facing tasks

• Improve overall approval rates and reduce denials

What Did We Learn?

Prior Authorization is a necessary component of today’s healthcare system but it doesn’t have to overwhelm your practice. With the right strategy, providers can navigate PA requirements smoothly and ensure patients get timely access to needed treatments.

Whether handled in-house or outsourced to a trusted partner, streamlining your Prior Authorization workflow is key to improving care delivery, optimizing billing, and reducing administrative burnout.

What People Are Asking?

Q: What is Prior Authorization in healthcare?
A: It’s a process where insurers require approval before covering certain medications or treatments.

Q: Why do insurance companies use Prior Authorization?
A: To ensure treatments are medically necessary and cost-effective.

Q: What services commonly require Prior Authorization?
A: Prescription drugs, surgeries, diagnostic tests, and durable medical equipment (DME).

Q: How does the Prior Authorization process begin?
A: The provider checks if the service needs PA and submits a request with clinical documentation.

Q: How long does Prior Authorization take?
A: It can take anywhere from a few days to several weeks depending on the case complexity.

Q: Can Prior Authorization requests be expedited?
A: Yes, urgent cases may qualify for faster review in hours or one business day.

Disclaimer

For informational purposes only; not applicable to specific situations.

For tailored support and professional services,

Please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com.

About This Blog : This Blog is brought to you by Staffingly, Inc., a trusted name in healthcare outsourcing. The team of skilled healthcare specialists and content creators is dedicated to improving the quality and efficiency of healthcare services. The team passionate about sharing knowledge through insightful articles, blogs, and other educational resources.