Clinical Scorecard: Insights on Prior Authorization

At a Glance

Key Highlights

• Prior authorization can take 3-5 minutes to complete, but may extend to 10-15 minutes.
• 94% of doctors believe prior authorizations negatively impact patient care.
• The appeals process for denied authorizations can take up to 30 days.
• Legislation is being proposed to reform the prior authorization process.
• Patients may remain untreated while waiting for authorization decisions.

Guideline-Based Recommendations

Diagnosis

• Ensure thorough documentation of past treatments, reactions, and allergies.

Management

• Utilize electronic platforms for submitting prior authorizations to streamline the process.

Monitoring & Follow-up

• Track the status of prior authorizations to prevent treatment delays.

Risks

• Delays in prior authorization can lead to untreated conditions and potential hospitalizations.

Patient & Prescribing Data

Patients requiring medications subject to prior authorization.

Patients often face delays and may need to try multiple medications before approval.

Clinical Best Practices

• Maintain clear communication between healthcare providers, pharmacies, and insurance companies.
• Educate staff on the prior authorization process to improve efficiency.
• Advocate for patients' rights to necessary medications during the authorization process.

References

• Reducing Medically Unnecessary Delays in Care Act of 2025