By the Time the Approval Arrives, the Patient Has Switched Providers

Prior authorization is approval a health plan requires before it will pay for a specific medication, test, or procedure — the provider submits clinical justification, and the payer reviews it against coverage criteria before care is delivered. Without that approval, the insurer can refuse to pay, leaving the patient responsible for the cost even if the care was medically appropriate.

According to the AMA's most recent physician survey, the average physician completes about 39 prior authorizations per week and spends roughly 13 hours a week — nearly two full business days — on the prior authorization process for themselves and their staff combined. That administrative load is a primary reason health systems invest in prior authorization automation rather than adding more staff.

93% of physicians in the AMA's survey reported that prior authorization at least sometimes delays access to necessary care, and 94% said it has a negative impact on patient clinical outcomes. For time-sensitive diagnoses and treatments, prior authorization delay is one of the most-cited criticisms of the current system from both physicians and patient advocates.

CMS-0057-F is a federal rule requiring certain health plans — including Medicare Advantage organizations, Medicaid and CHIP programs, and Qualified Health Plan issuers on the federally-facilitated exchanges — to build standardized, FHIR-based electronic APIs for prior authorization, cut decision turnaround times to 72 hours (urgent) and 7 calendar days (standard), and publicly report prior authorization metrics. Compliance was required beginning January 1, 2026.

Covered payers must decide urgent prior authorization requests within 72 hours and standard requests within 7 calendar days — down from the previous 14-day standard for many plan types. Payers must also provide a specific reason when denying a request, giving providers clearer grounds for a targeted documentation fix or appeal.

About 4 out of 5 — roughly 80% — of prior authorization appeals result in the original denial being overturned. Despite this high success rate, AMA survey data shows a majority of physicians do not always appeal adverse decisions, largely because many believe the appeal will not succeed. This gap between overturn rates and appeal filing rates represents a significant, recoverable revenue opportunity for most practices.