The Hidden Cost Nobody Calculates
When a prior authorization gets denied, most practice managers think about the obvious cost: the time it takes to appeal, the potential lost reimbursement, the frustrated patient who calls asking why their medication hasn’t been approved. But the true cost of a denied authorization goes much deeper — and most practices are severely underestimating it.
According to a 2023 AMA Physician Survey, physicians and their staff spend an average of 14.6 hours per week per physician completing prior authorization work. For a three-physician practice, that’s roughly 44 hours a week — more than a full-time employee — spent entirely on insurance paperwork instead of patient care.
“The prior authorization process was designed to control costs. In practice, it has become one of the most significant barriers to timely patient care — and one of the largest sources of preventable administrative burden in medicine.”— American Medical Association, 2023 Prior Authorization Physician Survey
Why Most Denials Are Actually Preventable
Here’s a fact that should change how you think about authorization denials: the majority of them are preventable. Not avoidable in a grand systemic sense — but preventable at the submission level, by doing the preparation work correctly before the request goes out the door.
The most common reasons prior authorization requests get denied are not medically defensible. They are administrative and preparatory failures:
- Incomplete documentation:Missing lab results, imaging reports, or physician notes that the payer required but weren’t included in the submission
- Step therapy not documented:Payer requires evidence of prior treatment failures, but those failures weren’t explicitly documented in the submission
- Wrong or missing diagnosis codes:The ICD-10 codes submitted don’t map to the payer’s approved indications for the requested treatment
- Letter of Medical Necessity absent or insufficient:No LMN was included, or the one included didn’t address the payer’s specific clinical criteria
- Submitted to wrong department or channel:The request went through the wrong portal or fax number, causing delays or outright rejection
- Payer-specific criteria not met on paper:
The Bottom Line
Prior authorization denials are not inevitable. The majority are preventable with better preparation, payer-specific documentation, and active case management that doesn’t stop at submission. The practices that consistently achieve 97%+ first-pass approval rates are not the ones with the best insurance — they’re the ones with the most rigorous pre-submission process.
If your team is spending significant hours every week on authorizations, dealing with repeated denials, or seeing cases fall through the cracks during the follow-up window, the problem isn’t your specialty or your payer mix. It’s the process — and process can be fixed.
We’d be happy to show you what that looks like in practice. Start with five complimentary authorizations and see the difference a clinical-first PA process makes.
