How Long Does Prior Authorization Take for Medication?

Prior authorization is a regulatory requirement set by insurance providers to control costs and ensure the appropriate use of high-risk or expensive medications. 

Although it has a purpose, the process is frequently associated with inefficiencies. An American Medical Association (AMA) survey found that 94% of physicians reported care delays due to prior authorization. 

Understanding how long prior authorization takes and how to minimize delays is crucial for ensuring timely patient care in your practice. 

In this article, we'll explore the typical timeframes for prior authorization for medications, key factors that affect processing speed, strategies to expedite approvals, and practical steps you can take to navigate denials or prolonged delays effectively in your practice.

How Long Does Prior Authorization for Medication Take?

The type of medications required, the prescription, the insurance company's policies, and the case's complexity all affect the prior authorization timeline. However, the following ranges are often where usual processing times fall:

• Standard approvals: prior authorization requests typically receive a response between 24 to 72 hours.
• Complex cases: Processing times may increase by 7 to 10 days if more information is needed.
• High-cost and specialty drugs: Depending on the insurer's rules and required medical documentation, they can take anywhere from 10 to 30 days.

Expedited processing is available for urgent cases only if the Physical Therapist demonstrates a critical medical necessity. Even then, insurers might not always approve instantly.

Although these timelines provide an overview, several factors can affect the processing time of a prior authorization request. 

Key Factors Affecting Prior Authorization Timelines

Timelines for prior authorization differ greatly. The effectiveness of submission techniques, insurer criteria, and document correctness are some factors affecting approval speed. By being aware of these challenges, physical therapists can reduce delays.

1. Paper-Based vs. Electronic Processing: The Speed Gap

Conventional fax and paper-based submissions are challenging, prone to mistakes, and require manual intervention at multiple stages. On the other hand, electronic prior authorization (ePA) automates essential steps, increasing approval rates and reducing processing times from days to hours. 

Platforms like Spry, which offer integrated EMR solutions, help automate and simplify prior authorization workflows, ensuring faster approvals—boasting a success rate of over 98%. Try SPRY for Free here!

2. The Impact of Incomplete or Incorrect Documentation

Incorrect forms, a missing medical history, or a lack of clinical justification frequently cause insurers to request more information, which delays approval. Ensuring complete and accurate submissions upfront can significantly reduce back-and-forth communication.

3. Variability in Insurance Policies and Requirements

The rules for verification, coverage limitations, and acceptance criteria vary from one insurance company to the other. Prior authorization processing timeframes might differ considerably between payers due to this lack of standardization, making consistency difficult. 

4. Breakdowns in Communication Between Stakeholders

Without real-time integration between physicians, pharmacies, and insurers, requests often get stuck in processing due to missed updates or miscommunications. A lack of direct insurer-provider connectivity can extend approval timelines unnecessarily.

5. The Reality of Expedited Requests and Appeals

While urgent cases can be fast-tracked, expedited approval isn't always guaranteed. Insurers may reject a request with inadequate or missing supporting evidence, forcing PT into an appeals process that causes additional delays.

These factors highlight the inefficiencies in traditional prior authorization methods, leading to significant consequences for patients and providers.

What Happens When Prior Authorization is Delayed?

Delays in prior authorization can cause more than minor inconveniences; they can also interfere with treatment plans, add to administrative pressures, and put patients through financial hardship. In addition to endangering patient health, delayed approvals cost healthcare professionals valuable time and resources and reduce system efficiency. 

1. Patient Health Risks

When prior authorization stalls, patients may experience delays in starting essential medications, leading to worsening symptoms, increased hospitalizations, and potential long-term complications. In urgent cases, prolonged wait times can have serious consequences. 

If a delay occurs, Physical Therapists can explore alternatives like recommending covered treatments, submitting an expedited request, or appealing denials to minimize disruptions.

2. Administrative Burdens on Healthcare Providers

Prior authorization requirements take up an average of 13 hours per week for physicians and staff, taking time away from patient care. The manual workload, frequent follow-ups, and paperwork-intensive procedures unnecessarily burden healthcare teams.

Pharmacy-led prior authorization teams and automated systems like Spry can ease this burden, speeding up the process and reducing manual work.

3. Financial Strain on Patients

While waiting for approval, some patients resort to paying out-of-pocket for high-cost medications, which can impact their finances. Others may skip or postpone treatment, raising the possibility of complications and future medical expenses. 

Platforms like Spry offer automated prior authorization solutions, integrating with EMRs to reduce paperwork, accelerate approvals, and eliminate unnecessary back-and-forth—helping PTs focus more on patient care. Check out the services here!

In light of these challenges, you must consider improving efficiency by streamlining the prior authorization process in your practice. 

How to Speed Up Your Prior Authorization Process? 

Proactive management, strategic workflows, and the right technology can frequently prevent prior authorization delays. Here are some key approaches to speed up the procedure while maintaining compliance. 

1. Electronic Prior Authorization (ePA):

• Eliminates errors and missing data by automating real-time eligibility verification.
• It reduces the need for fax, phone calls, and manual processing by cutting up to 70% turnaround times.

2. Real-Time Prescription Benefit (RTPB) Tools:

• Allows providers to immediately check if a medication requires PA before prescribing.
• Reduces approval bottlenecks by recommending alternative medications that might be covered without prior authorization.

3. Pharmacy-Led Prior Authorization Teams:

• Assigns dedicated staff to handle PA submissions, easing the burden on physicians.
• Enhances communication between pharmacies, providers, and insurers, guaranteeing quicker approvals and eliminating errors.

Platforms like SPRY offer advanced electronic prior authorization capabilities, seamlessly integrating with EMR systems to reduce administrative delays and improve approval rates! 

While internal workflow improvements help, outsourcing prior authorization services can offer an even quicker and more effective alternative for high-volume practices. 

Outsourcing Prior Authorization Services: Is It the Right Move?

Many healthcare facilities are outsourcing PA services to specialist third-party providers due to the increasing complexity of authorization requirements. These services offer faster approvals, reduced administrative burdens, and 24/7 availability, making them a viable option for high-volume practices. 

Here's why outsourcing could be a game-changer: 

1. Faster Processing & Higher Approval Rates:

• Dedicated PA teams accelerate approvals by streamlining submissions and reducing errors.
• Expertise in payer requirements lowers denial rates, ensuring smoother processing.

2. Cost Savings Over In-House Processing:

• Eliminates the need for additional administrative staff, cutting operational costs.
• Allows healthcare providers to focus on patient care instead of paperwork.

3. Round-the-Clock Support for Urgent Requests:

• 24/7 availability ensures that prior authorization requests are processed promptly.
• Platforms like Spry continuously process requests, preventing bottlenecks. Ensures urgent approvals are handled efficiently, even outside business hours.

Healthcare providers must adopt automation, proactive management, and the appropriate technology to expedite approvals to decrease prior authorization setbacks.

Conclusion

Prior authorization is essential for cost control and patient safety, but delays can disrupt treatment, burden healthcare providers, and create financial strain. Although complex cases may take up to 30 days to approve due to manual inefficiencies, insurer regulations, and documentation problems, standard approvals take 24 to 72 hours. 

Streamlining the process with electronic prior authorization, pharmacy-led PA teams, and outsourcing services can improve turnaround times.

Physical Therapists can speed up approvals, reduce administrative load, and automate prior authorization workflows using platforms such as SPRY. SPRY guarantees quicker, more effective PA processing by integrating seamlessly with EHR systems, reducing delays that affect patient care.

Request a free trial today and experience faster, hassle-free prior authorization with SPRY!