Managing Prior Authorizations: How to Prevent Dangerous Treatment Delays

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.