Rethinking Prior Authorization: Bridging Clinical Needs and Administrative Burdens

ABSTRACT

Prior authorization (PA) is a widely used insurance mechanism intended to ensure cost-effective, evidence-based care. However, in practice, it often imposes significant administrative and clinical burdens on health care providers and delays patient access to timely treatment. This article draws on firsthand experience in managing PAs for complex therapies, such as pediatric growth hormone treatments, to explore the evolution of PA, current operational challenges, and practical strategies for improvement. Key issues include limited formulary flexibility, step therapy requirements, lack of specialized peer review, and insufficiently trained staff handling PAs. To address these barriers, the article proposes workflow enhancements such as assigning clinically trained PA specialists, leveraging electronic platforms, using real-time benefit tools, and developing internal reference guides. By adopting structured, clinically informed approaches, health care practices can streamline PA processes, reduce turnaround times, and enhance patient care outcomes.

Am J Manag Care. 2026;32(2):In Press

Takeaway Points

This article offers actionable strategies to optimize prior authorization (PA) processes, which could help health care practices reduce delays, improve medication access, and align clinical care with administrative requirements. Measures to support better clinical outcomes and inform policies that prioritize timely, patient-centered care include the following:

• Assign clinically trained staff to manage PAs, ensuring accurate and efficient submissions.
• Utilize electronic platforms and real-time benefit tools to streamline communication with insurers.
• Maintain updated internal reference guides on step therapy and insurance criteria.
• Escalate complex cases through peer-to-peer reviews with specialty-matched physicians to prevent inappropriate denials.

Prior authorization (PA) is a structured process implemented in the US health care system to control costs associated with medications and medical procedures covered by insurance plans—including Medicare, Medicaid, and commercial insurers. Under this system, health care providers must obtain prior approval from the insurance provider before proceeding with certain prescriptions or treatments. This process typically requires submitting clinical documentation, justification for therapy, and relevant patient history.

Although initially introduced as a cost-containment strategy, PA also aims to:

• prevent harmful drug interactions;
• ensure adherence to step therapy protocols;
• confirm patient adherence and suitability;
• support evidence-based prescribing using laboratory values and treatment history; and
• promote lifestyle changes that enhance treatment outcomes.

Evolution of PA

In its early days, PA was a manual and cumbersome process involving paper forms, faxes, and phone calls. Providers had to download forms, fill them in manually, and fax supporting documentation. Alternatively, they could spend time on calls with insurance representatives, verbally answering clinical questions.

To simplify this, many insurance companies began partnering with platforms such as CoverMyMeds, enabling providers to select and complete electronic forms, upload required documents through a centralized portal, and monitor real-time authorization statuses.

Despite these advancements, insurance providers and pharmacy benefit managers still take an average of 48 hours or more to respond.¹To address urgent cases, an “emergency request” category was introduced, mandating a faster response—often within a few hours.²

Recently, some payers have implemented instant approvals for medications that meet basic criteria based on a short questionnaire. Moreover, prescribers can now see whether a medication requires PA before submitting a request and can view alternative covered drugs during the authorization process, allowing for immediate adjustments if needed (although alternatives may also require PA).

Challenges in PA: A Closer Look

Although the intention behind PA is sound, the practical execution presents several challenges for providers and patients alike.

Limited formulary options. Annual updates to formularies often reduce available medication options, forcing providers to choose from a restricted list. For example, somapacitan-beco (Sogroya), a once-weekly growth hormone injection, might not be covered unless somatropin (Norditropin), a daily injectable, is tried and failed—despite not being on the formulary itself. Patients, especially children, often prefer weekly over daily injections, and such limitations can cause anxiety and treatment delays.

Lack of clinical expertise among staff. Medical assistants or office staff tasked with managing PAs may lack the pharmacological knowledge to answer clinical questions effectively.³ For instance, insurers may ask whether a patient has tried and failed sodium-glucose cotransporter 2 inhibitors before approving another antidiabetic medication—a question that requires understanding of therapeutic classes and treatment protocols.

Step therapy restrictions. Providers often want to skip less-effective treatments, especially when a patient’s health is deteriorating. For example, in pediatric endocrinology, physicians may prefer initiating therapy with somatropin (Humatrope) when a child’s growth curve shows alarming decline, rather than wasting time on trial and error with other medications. Step therapy, however, may mandate failing alternative drugs first, delaying necessary care.

Inadequate peer review. Insurance decisions are sometimes made by reviewers who do not specialize in the relevant field. For example, a pediatric endocrinologist’s prescription might be evaluated by a general practitioner, resulting in inappropriate denials.⁴ Only specialists in the same field can fully comprehend the urgency and clinical nuance involved.

Overly complex authorization criteria. PA criteria documents can be difficult to interpret, even for experienced providers. Requirements such as “the patient must have A, B, or C,” with A further broken into subcriteria⁵—some of which must be met in combination—can make the process unintuitive and error-prone.

Steps to Improve PA in Health Care Practice

To reduce delays, minimize rework, and improve patient care, health care practices can implement the following strategies:

1. Assign Dedicated PA Specialists

• Hire or train staff with a solid understanding of pharmacology and insurance protocols.
• Designate a dedicated team member (preferably with clinical training) to handle all PAs.

2. Utilize Electronic PA Platforms

• Make full use of platforms such as CoverMyMeds or Surescripts for electronic submissions.
• Leverage their tracking and alerts systems to stay updated on PA status and respond to insurer requests promptly.

3. Integrate Real-Time Benefit Tools

• Use electronic prescribing tools that show real-time formulary options, PA requirements, and cheaper therapeutic alternatives at the point of care.

4. Maintain a Reference Guide for Step Therapy and Criteria

• Create an internal database or quick-reference sheet listing commonly prescribed medications, their step therapy requirements, and insurance-specific criteria.
• Update this regularly based on insurer changes.

5. Establish a Peer-Review Escalation Pathway

• For complex or denied cases, insist on peer-to-peer reviews with a physician of the same specialty.
• Prepare supporting documentation that highlights the urgency and justification for bypassing step therapy.

6. Improve Provider-Staff Communication

• Set up standardized forms or checklists that providers fill out during the consultation, noting past medications tried, laboratory results, and relevant clinical notes. This ensures that the assistant or PA specialist has all the necessary information to submit a complete request.

7. Track and Audit PA Outcomes

• Maintain a dashboard to monitor approval/denial rates, turnaround time, and frequently denied medications.
• Use these data to identify trends and retrain staff or adjust prescribing habits accordingly.

8. Engage With Insurers

• Collaborate with insurance representatives to clarify complex criteria.
• Request educational webinars or documentation to train staff in navigating their systems.

Conclusions

Although PA is designed to promote safe, cost-effective health care delivery, the practical burden on providers and patients is substantial. From limited formularies to time-consuming processes and poorly structured criteria, the current system demands thoughtful improvement. By investing in staff training, embracing digital tools, and establishing clear workflows, practices can streamline the PA process—ensuring timely care and minimizing frustration for all stakeholders.

Author Affiliation: Tamil Nadu Dr. M.G.R. Medical University, Tamil Nadu, India.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; administrative, technical, or logistic support; and supervision.

Address Correspondence to: Gokul Sampathkumar, PharmD, Tamil Nadu Dr. M.G.R. Medical University, Chennai, Tamil Nadu, India 600032. Email: ggokul76@gmail.com.

REFERENCES

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