Prior Authorization Action Planner
Your Prior Authorization Plan
This tool helps you navigate the prior authorization process and avoid dangerous treatment delays. Based on your situation, we'll provide personalized action steps.
Imagine you’re prescribed a life-saving medication. Your doctor signs the script, you head to the pharmacy, and then you’re told: “We can’t fill this until your insurance approves it.” That approval could take days. Or weeks. And during that time, your condition worsens. This isn’t a rare scenario-it’s happening to millions right now, and the delays aren’t just frustrating. They’re deadly.
What Is Prior Authorization, Really?
Prior authorization is a gatekeeping step used by insurance companies to approve certain treatments, medications, or tests before they’re given. It’s meant to stop unnecessary care and control costs. But in practice, it often blocks necessary care. For example, if you have multiple sclerosis and your doctor prescribes a specialty drug that costs $10,000 a month, your insurer might demand you try three cheaper drugs first-even if those drugs won’t work for you. Or if you need an MRI for back pain, they might require a letter from your doctor, lab results, and a signed form-all sent by fax-before they’ll pay for it. The system was designed to protect patients, but it’s become a bottleneck. Medicare Advantage plans require prior authorization for nearly 25% of prescriptions. Commercial insurers demand it for 60% of specialty drugs. And Medicaid? The rules change by state. One state might approve a drug in 2 days. Another might take 3 weeks.Why These Delays Are Life-Threatening
It’s not just about inconvenience. When treatment is delayed, outcomes get worse. A 2023 study in JAMA Oncology found that cancer patients who waited more than 28 days to start treatment had a 17% higher risk of dying. That’s not a small number. That’s one in six. Diabetic patients have gone into diabetic ketoacidosis because their insulin pump authorization was stuck. Transplant patients missed doses of immunosuppressants and suffered organ rejection. Epilepsy patients had seizures because they couldn’t afford their medication while waiting for approval. In one documented case, a patient died after a seizure because the insurance company hadn’t approved their drug yet. These aren’t outliers. In a 2024 survey of 945 doctors by the American Medical Association, 91% said prior authorization led to negative health outcomes. 82% said patients gave up on treatment entirely because the process was too hard. And 34% reported serious harm-like hospitalizations or permanent damage-directly tied to delays.How the System Still Works (And Why It’s Broken)
Despite all the talk about digital health, most prior authorization requests still go out by fax. In 2024, 85% of requests were submitted manually-phone calls, paper forms, faxes. Only 15% used electronic systems. That means a doctor’s office has to print, sign, fax, wait for a call back, and then maybe do it all again if the form was incomplete. Doctors and their staff spend an average of 16 hours a week just managing these requests. That’s more than two full workdays. And for what? To wait for a response that often comes back as a denial-sometimes for arbitrary reasons. One doctor reported being told a patient’s migraine medication wasn’t approved because “the diagnosis code didn’t match the drug.” The drug was FDA-approved for migraines. The code was correct. But the insurer’s system didn’t recognize it. Meanwhile, insurance companies save money. Prior authorization reduces utilization of expensive services by 15-22%. But those savings come at the cost of patient safety. And the administrative cost? Over $31 billion a year in the U.S. alone.
Who Gets Hurt the Most?
The system doesn’t treat everyone equally. People with chronic illnesses-diabetes, cancer, autoimmune diseases-are hit hardest. So are low-income patients, older adults, and those in rural areas with fewer providers. Medicaid patients face the longest delays. On average, approvals take 7.2 business days-compared to 4.7 days for commercial insurers. And in some states, the process is so chaotic that patients wait longer than the legally required 14 days for non-urgent cases. Patients without strong advocates-family members, case managers, or patient navigators-are often left stranded. One Reddit user, a nurse, shared how a diabetic patient ended up in the ER after an 11-day delay. The patient didn’t know how to appeal. No one explained the process. They just ran out of medication and got sick.How Providers Can Reduce Treatment Gaps
There are ways to fight back. And many clinics are already doing it.- Use electronic prior authorization (ePA): Practices that switched to ePA cut approval time from over 5 days to under 2 days. Some systems now show real-time status updates inside the electronic health record.
- Verify benefits before the appointment: Checking insurance coverage upfront reduces authorization needs by nearly 30%. If you know a drug requires prior auth before you even write the prescription, you can plan ahead.
- Use standardized templates: Many insurers accept the same form for the same drug. Creating a template for common requests cuts documentation time by 40%.
- Build a prior auth team: Even small practices can assign one person to handle authorizations full-time. That single change improved approval rates by 22% in pilot programs.
- Use bridge therapy: If a patient needs a drug immediately, some providers keep a 7-14 day supply on hand to tide them over. It’s expensive for clinics, but it saves lives.
What Patients Can Do to Protect Themselves
You don’t have to wait passively for approval. Here’s what you can do:- Ask about prior authorization before you leave the doctor’s office. “Will this medication need approval?” If the answer is yes, ask how long it usually takes. Get the name of the insurer’s prior auth department.
- Call your insurer yourself. Don’t wait for your doctor’s office. Call the number on your insurance card and ask: “Is this drug covered? What’s the prior auth process? How long does it take?” Write it down.
- Ask about patient assistance programs. Many drugmakers offer free medication for patients waiting on approval. You don’t have to go without.
- Know your rights. Federal law says urgent requests must be decided in 72 hours. If you’re waiting longer, you can appeal. And if you’re in a life-threatening situation, you can request an expedited review.
The Future Is Changing-But Not Fast Enough
Good news: change is coming. In January 2024, the Centers for Medicare & Medicaid Services (CMS) ruled that by December 2026, all Medicare Advantage and Medicaid plans must use electronic systems with real-time approval capabilities. That’s huge. Right now, if a doctor prescribes a drug at 10 a.m., they might not know if it’s approved until 10 a.m. the next day. In 2026, they could know in seconds. New technology is helping too. AI tools like Kyruus and Apricus Analytics are predicting which requests will be approved or denied before they’re even submitted. Some health systems are using HL7’s PDEX standard to check authorization status right in the EHR-before the prescription leaves the office. But here’s the catch: 63% of Medicaid programs still use fax machines. And 41% of doctors say they haven’t seen any real improvement yet. The system is slow to change. And until it does, people are still dying in the gaps.Final Thought: This Isn’t Just a Bureaucratic Problem-It’s a Safety Crisis
Prior authorization was never meant to be a barrier to care. It was meant to ensure care was appropriate. But today, it’s often a barrier to survival. The data is clear: delays cause harm. Patients are suffering. Providers are burned out. And the system is failing the people it claims to protect. The solution isn’t to eliminate prior authorization entirely. Some high-cost treatments need review. But we need smarter, faster, patient-centered rules. Real-time decisions. Fewer faxes. Clearer standards. And accountability when delays lead to harm. Until then, if you’re a patient, ask questions. If you’re a provider, fight for your patients. And if you’re a policymaker-remember: every day a patient waits is a day they could lose.What is prior authorization and why does it cause treatment delays?
Prior authorization is a process where your insurance company requires approval before covering certain medications, tests, or procedures. It’s meant to control costs, but it often causes delays because approvals require paperwork, faxes, and phone calls. Many requests are denied or take days to process, leaving patients without needed care. In emergencies, these delays can lead to hospitalizations or death.
Which types of treatments commonly require prior authorization?
High-cost medications-especially specialty drugs like those for cancer, MS, or rheumatoid arthritis-are the most common. Other examples include MRIs, CT scans, surgeries, durable medical equipment like oxygen tanks, and certain mental health therapies. Even some generic drugs require prior auth if they’re part of a step therapy program.
How long does prior authorization usually take?
For non-urgent requests, it can take 5 to 14 days, depending on your insurer and state. Medicaid averages 7.2 business days. Medicare Advantage takes about 5.3 days. Commercial insurers are faster, around 4.7 days. But for urgent cases, federal law requires a decision within 72 hours. If you’re in danger, you can request an expedited review.
Can I get my medication while waiting for approval?
Yes, but not always easily. Some clinics keep a short supply of critical medications to use as a bridge while waiting for approval. Drug manufacturers also often have patient assistance programs that provide free medication during delays. Ask your doctor or pharmacist about these options-don’t wait until you’re sick.
What should I do if my prior authorization is denied?
Don’t accept the denial. Ask your doctor to appeal. They can submit additional clinical notes or evidence that the treatment is medically necessary. You can also call your insurer directly and request a formal review. Keep records of every call, email, and form. Many denials are overturned on appeal-especially when supported by your doctor’s documentation.
Is there a law that protects me from long delays?
Yes. Federal law requires insurers to respond to urgent requests within 72 hours and non-urgent ones within 14 days. If they don’t, you can file a complaint with your state’s insurance department or CMS. In 2024, new rules require Medicare Advantage plans to use electronic systems by 2026, which will speed up decisions significantly.
Sarah Triphahn
January 14, 2026 AT 03:32This system is just capitalism with a stethoscope. Insurance companies aren't here to save lives-they're here to save dollars. And we're the collateral.
Every time someone dies waiting for a fax, it's not an accident. It's a business decision.
Vicky Zhang
January 14, 2026 AT 18:22I work in a clinic and I see this every single day. One of my patients with MS waited 18 days for her drug. She ended up in the hospital. Her kids were scared. Her husband had to quit his job to take care of her. And the insurance rep said, 'We didn't get the form signed correctly.'
It's not just frustrating-it's soul-crushing. We need to stop pretending this is about efficiency. It's about greed.
And if you're a provider, please, please, please start using ePA. Even if it's just one form at a time. Change starts with us.
Sarah -Jane Vincent
January 16, 2026 AT 01:46Oh please. This is just another liberal sob story. Insurance companies have to protect against fraud. What if someone's faking MS to get free drugs?
And who says all these delays are deadly? Maybe people just need to stop being lazy and call their own damn insurer.
Also, fax machines? That's not broken-that's legacy tech. We still use landlines. Should we ban those too?
And why are we letting bureaucrats dictate healthcare? Sounds like socialism with a co-pay.
Henry Sy
January 17, 2026 AT 04:30Bro. I had a cousin die because his insulin pump got stuck in prior auth hell. He was 24. Had a job. Had insurance. Thought he was covered.
They denied it because his HbA1c was 'too high'-like that was the problem. The problem was they didn't give a shit.
Now I scream at every insurance rep I talk to. I record every call. I send copies to the state AG. And I tell every diabetic I know: don't wait. Call. Now. Don't trust the doctor's office to do it.
They don't care. You have to care for them.
Anna Hunger
January 18, 2026 AT 15:24While the emotional weight of this issue is undeniably profound, it is imperative to acknowledge the structural inefficiencies inherent in the current prior authorization framework. The administrative burden imposed upon healthcare providers is not merely a logistical inconvenience-it constitutes a systemic failure in care coordination.
Furthermore, the persistence of manual submission methods in the face of available digital infrastructure represents a profound misallocation of resources. The $31 billion in administrative expenditures could be redirected toward patient care, workforce support, or technological modernization.
It is not a question of whether prior authorization should be abolished, but rather how it may be re-engineered to prioritize clinical necessity over financial arbitrage.
Jason Yan
January 19, 2026 AT 14:03It's wild when you think about it-we've got AI that can predict your next Netflix show, but we still fax prescriptions for life-saving drugs?
There's something deeply wrong when the system that's supposed to protect you is the same one that kills you slowly, quietly, one denial at a time.
And the worst part? No one's in charge. No one's accountable. The insurance rep who says 'no' doesn't see the patient. Doesn't hear the family crying. Doesn't feel the weight of that decision.
Maybe we need a law that says: if your decision causes harm, you lose your job. Not just the provider. YOU.
Until then, we're just screaming into a void.
shiv singh
January 20, 2026 AT 20:49USA is the only country where you need permission to live. In India, if you need medicine, you go to the pharmacy. If you can't pay, you beg. But you don't wait 14 days for a fax to decide if you get to breathe.
And now you want to fix it with tech? No. Fix the greed. Fix the CEOs who make $20 million while people die.
Stop pretending this is about 'cost control.' It's about control. Period.
Robert Way
January 22, 2026 AT 14:29so i had this thing where my doc said i needed a mri but the insurace said no so i called and they said they need a letter from the doc and the doc said they already sent it and i was like wait what and then i found out the fax got lost and then i had to get a new form and then they said the form was wrong and then i gave up and just paid out of pocket and now im broke but alive so yk what i learned
trust no one
Allison Deming
January 23, 2026 AT 05:31It is both morally indefensible and economically irrational to allow bureaucratic processes to supersede clinical judgment in matters of life and death. The American healthcare system has, in effect, outsourced its ethical obligations to for-profit entities whose fiduciary duty is to shareholders-not patients.
The fact that 91% of physicians report negative health outcomes due to prior authorization is not a statistic-it is a public health emergency.
Any policy that permits a non-clinical entity to delay or deny treatment based on arbitrary criteria is not healthcare policy. It is institutionalized cruelty.
Susie Deer
January 23, 2026 AT 17:53Why do we even have insurance if we're gonna let them stop us from getting medicine
Just make it free. Like Canada. Or Europe. Or anywhere else that doesn't let corporations play god with people's lives
And if you think it's expensive now wait till you see the funeral bills
TooAfraid ToSay
January 25, 2026 AT 09:19Everyone says it's the insurance companies but what about the doctors? Why don't they just write better forms? Why do they use fax? Why don't they train their staff? Why do they blame the system instead of fixing it?
It's not the system. It's the people in it.
And don't tell me they're overworked. I work 80 hours a week too. But I don't let patients die because I'm tired.
Dylan Livingston
January 25, 2026 AT 12:14Oh honey. You think this is bad? Wait until you find out that the same insurers who deny your insulin are the ones funding the lobbyists who wrote the laws that let them do it.
And the doctors? They're just cogs. They're paid by volume, not outcomes. They don't care if you live or die-they care if you show up next week.
And the patients? They're just numbers on a spreadsheet. With a pulse.
It's not a broken system. It's a perfectly designed one. For profit.
And you're the cost center.
Andrew Freeman
January 27, 2026 AT 00:41all this talk about ePA and tech but no one talks about how most docs cant even use a computer right
i had a doc try to fax a form and he sent it to his own email by accident
then he called the insurance and said 'uhh i think i sent it to the wrong place' and they were like 'we never got it'
so we started over
and the patient got worse
and no one even laughed
they were all just tired
says haze
January 28, 2026 AT 14:17It's not merely a failure of infrastructure-it is the epistemological collapse of medical authority. The patient's body has become a site of contractual negotiation, where biological necessity is subordinated to actuarial calculus.
When a machine denies a life-saving drug because the diagnosis code does not align with its proprietary algorithm, we are no longer practicing medicine. We are administering compliance.
The true horror is not the delay-it is the normalization of it. We have been trained to accept death as a line item.
Alvin Bregman
January 30, 2026 AT 06:37my dad was a nurse for 40 years. he used to say the hardest part of his job wasn't the long hours or the blood or the pain.
it was watching people cry because they couldn't get their medicine and knowing no one in the system would care enough to fix it.
i don't know if things will get better. but i know we have to keep talking. keep calling. keep fighting.
because if we don't, who will?