Prior Authorizations: 5 Ways to Beat the Hurdles

Leigh Page


January 08, 2019

In This Article

Educate Yourself on Appeal Rights

Under the Affordable Care Act, insurers are required to provide an appeal mechanism. You may request an external appeal by an independent third-party reviewer, and if you have a medical urgency, you can qualify for urgent or expedited review within 72 hours or sooner, according to the AMA.[14]

The appeals process involves providing documentation through faxes or portals, and then waiting for a decision. This can take a while. Appealing step therapy protocols, for example, may take months to resolve.[15]

Appealing a prior authorization decision can be used as a malpractice defense, according to a 2014 report on a 1986 opinion in the California courts.[16] That report added that courts frown upon doctors who adopt plans' cost-cutting mentality. Courts have ruled that doctors are bound by "the standard of reasonable community practice" and should not let cost limitations "corrupt medical judgment," according to the report.

Don't expect plans to base their prior authorization decision on your notion of the standard of care, such as appropriate use criteria (AUC) developed by your specialty society. A new study published by the American College of Cardiology found that payers weren't using the college's AUC two thirds of the time and were instead relying on their own proprietary criteria.[17]

5. Consider Outsourcing Tough Cases

Processing companies, such as AuthNet or Azalea Health, can be a way to let practices continue to carry out most of their own requests but not get tied up in the really tough cases.

"Clients often send us their difficult cases, or they use us when they're backed up," says Bollinger at AuthNet. Boudreaux adds that Azalea Health doesn't accept cases that need to be approved within 48 hours in advance or stat cases with a 24-hour turnaround.

Azalea Health sets up a dashboard for each claim, showing the patient's name, basic clinical information, the scheduled date, and the status of the request.

By handling a large volume of cases, processing companies say they develop insights into prior authorization processes that practices with smaller volumes may not have. "The number of authorizations we handle per month is well into the five-figure range," Bollinger says.

Bollinger says AuthNet charges a one-time implementation charge and then charges per prior authorization in the range of $6-$9 per case.


After increasing the number of prior authorizations required, payers may be on the road to creating many key reforms of the prior authorization process.

They have been embracing ePAs and are now discussing ways to reduce the number of prior authorizations and further simplify the process. But it is a slow evolution, and everyone is aware that the system will go not away.

"In time, the process will be streamlined and prior authorization will be easier," Bollinger predicts.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.