While intended to promote appropriate utilization, ensure medical necessity, and control healthcare spending, prior authorizations can have negative consequences on patient care. More specifically, prior auths can delay treatment, increase administrative burden, and negatively affect the patient experience. Understanding the impact of prior authorizations on patient care—and taking proactive steps to address any barriers—helps practices (and patients) ensure appropriate use of services. 

TL;DR

Prior authorization requirements — used by insurers to control costs and verify medical necessity — are creating significant delays in patient care. Practices now average 40 prior auth requests per physician per week, contributing to treatment interruptions, worsening outcomes for patients with chronic conditions, and substantial administrative burden on clinical teams. The inconsistency across insurance plans compounds the problem. Standardizing workflows, improving documentation quality, and adopting integrated technology are the most effective ways to reduce delays and protect both patient care and practice revenue.

Prior authorization requirements have existed for decades, but their volume and scope are expanding rapidly. Today, medical practices complete an average of 40 prior authorization requests per physician, per week, according to the American Medical Association (AMA). Even Medicare requires approval for certain services, though there is a federal push toward electronic prior authorization beginning January 1, 2027.

This aggressive growth is driven by three main factors:

In response to this growing administrative burden, a federal mandate is pushing for the adoption of automated, electronic prior authorizations.

However, despite these well-intentioned efforts, prior authorization can negatively affect patient care by delaying diagnoses and treatment, disrupting care plans, increasing patient stress, and creating barriers to timely access to medically necessary services.

Prior authorization requirements may prevent patients from receiving medications, diagnostic tests, procedures, referrals, or follow-up services in a timely manner. 

Consider a post-surgical patient who requires physical therapy to regain strength and function. Delays in authorization for therapy services can slow recovery and increase the risk of long-term functional limitations. Or a patient with severe fatigue and suspected sleep apnea. Prior authorization delays sleep testing, prolonging symptoms and delaying treatment that could improve quality of life and reduce health risks.

For patients with conditions such as diabetes, heart failure, cancer, autoimmune diseases, multiple sclerosis, rheumatoid arthritis, or behavioral health disorders, prior authorization delays can lead to worsening symptoms, disease progression, avoidable complications, reduced medication adherence, or increased use of emergency and inpatient services. 

Take diabetes management, for example. When a continuous glucose monitor requires prior authorization, a patient is left unable to closely monitor blood sugar levels, increasing the risk of uncontrolled diabetes and related complications. Similarly, a patient with rheumatoid arthritis forced to wait weeks for a critical biological medication may suffer irreversible joint damage and escalating pain while the paperwork sits in limbo. 

When authorizations stall, care plans fracture. Delays in approving diagnostic tests or specialist referrals directly contribute to treatment interruptions and preventable disease progress. For instance, a patient with worsening heart failure who is forced to wait weeks for a medication approval requiring prior authorization may end up in the emergency room — an expensive, stressful outcome that could have been avoided with timely access to care.

Or consider an older adult who is discharged from the hospital after a stroke and needs immediate transfer to a rehabilitation facility. Because the patient's Medicare Advantage plan requires prior authorization, admission to the rehab facility is delayed for several days. During the wait, the patient misses valuable therapy time, experiences a disruption in the care plan established by the hospital team, and may face a slower recovery and poorer functional outcomes.

Obtaining prior authorizations for patient care places a significant operational burden on practices by increasing administrative workload, delaying care delivery, consuming staff resources, and creating revenue cycle risks through denials and payment delays. Ninety-two percent of surveyed medical group practices reported hiring or reassigning staff solely to handle the growing volume of prior authorization requests. To mitigate these disruptions, many practices rely on medical billing software to steady their cash flow. Here’s a summary of key operational impacts of prior authorizations on today’s medical practices:

Prior authorizations also place substantial administrative strain on physicians and care teams by requiring extensive documentation, payer communication, status tracking, and appeals management, diverting valuable time and resources away from direct patient care. To protect their bottom line, some providers explore the ethics and legality of charging patients for prior authorization processing.

Even when providers follow evidence-based guidelines, payers often require additional clinical notes, test results, treatment histories, imaging reports, or documentation demonstrating that patients have tried alternative therapies first. In some cases, practices must submit the same information multiple times or reformat it to meet different payer requirements.

With prior authorizations on patient care, staff must first use real-time insurance eligibility tools to verify benefits, determine whether authorization is required, gather clinical documentation, complete payer-specific forms, and submit requests through multiple portals.

Obtaining prior authorizations for patient care causes friction because it puts providers in the position of seeking approval from payers for treatments they have already determined are medically appropriate for their patients. Over time, repeated authorization challenges can erode trust and make collaboration more difficult.

A medication, procedure, diagnostic test, or service that requires no authorization under one insurer may require extensive review, documentation, or step therapy under another. These differences create operational complexity and make workflows more complex and time-consuming.

A service that one insurer quickly approves may require extensive documentation, additional review, or even be denied by another. Why do these inconsistencies occur? Because of variations in coverage policies, medical necessity criteria, utilization management strategies, contracted vendors, and interpretation of clinical guidelines. As a result, physicians may encounter different authorization outcomes despite recommending the same evidence-based treatment for patients with similar conditions.

Each payer’s prior authorization criteria may not fully account for the nuances of an individual patient's medical condition, treatment history, or unique clinical needs. This means payer policies for prior authorizations may not align with clinical guidelines, medical history, and individual circumstances.

Fortunately, organizations can take proactive steps to reduce prior authorization delays. Standardization, documentation improvement, and technology are at the heart of these efforts.

Create a consistent, repeatable prior authorization process for identifying authorization requirements, gathering documentation, submitting a prior authorization request, tracking and obtaining approvals, and managing denials regardless of provider, specialty, or location.

Ensure documentation includes the following critical elements for obtaining prior authorizations for patient care:

Providers should include one or more of the following types of technology to improve the process of obtaining prior authorizations: