Prior authorization is a requirement in the United States for healthcare practitioners to seek a payer’s authorization before rendering a service. Physicians have to wait for insurance providers, and the patient care is stopped till the process has been completed. This requirement is frustrating for professionals.
The question that almost every patient and provider asks is how long does prior authorization take in the U.S? The truth is that there is no single answer to this question. Some authorizations might take a few hours for their approval, while others may take days or even weeks in worst-case scenarios.
Related Guide: What does Prior Authorization Mean
We have covered the same issue in this blog post. We will talk about the prior authorization, how long it takes in the U.S, and what the procedure of the prior authorization is for healthcare professionals. So let’s dig deeper into the topic.
What Is a Prior Authorization?
Prior authorization is also called pre-authorization, and it is a requirement from the insurance companies for physicians. Doctors need to get pre-authorizations before delivering a medical service to make sure that they will get paid by the insurance providers.
If we see the requirement from the payer’s perspective, it ensures that the service is medically necessary and that it is aligned with the policies of the payer as well. Prior-auths are usually necessary for the high-cost services like surgeries and operations.
Why Timing Is Important in Prior Authorization
Time is everything when it comes to the healthcare industry. Even a small delay can affect patient treatment, medication therapy and other medical processes. If patients have to face long delays in their treatments, it can lead them to depression, anxiety and even serious medical complications in case of chronic diseases.
There are two aspects in the prior authorization as well. In the first case, doctors need to submit a prior authorization request. This submission needs to be quick whenever required. The second case is when the authorization request has been submitted, and now the delay is in the acceptance procedure. Both of these delay types adversely affect patients.
How Long Does Prior Authorization Take in the U.S?
As there is no single timeframe for prior authorization approvals, it is necessary to understand how long it might take. Actually, these timelines vary based on the payer, service, submission time and the nature of the case. However, there are some standard time frames that various insurers follow. Here they are:
General Prior Authorizations (1-3 Business Days)
For general prior authorizations that are non-urgent in nature, most of the companies respond within 24 to 72 hours. These services often include outpatient services, medical equipment, imaging and others. They don’t have many complications as they are simpler to process.
However, it may take more time if there is a need for additional documentation by the insurers or if the documentation is not complete. Completion of documents is important to make this authorization quick and successful.
Urgent Requests (Within 24 Hours)
There are some tasks that need urgent handling and treatment. Any delay in the process can cause serious problems and threats to the patient’s health. These cases are usually handled and approved within 24 hours or the same day of the submission.
Doctors submit these requests in time-sensitive matters. However, insurance providers decide whether the request is urgent or not. If they don’t think that request is urgent, they can downgrade it to normal as well. This action can extend the review time.
Complex Authorizations (10-14 Days)
Prior authorizations for things like specialty medication, injectables, oncology medicines, advanced imaging and related services are often complex. Doctors need to talk to insurance providers to coordinate in additional paperwork required for the approval.
It may take up to two weeks before they are approved. Sometimes, it may take even longer than that based on the individual case and the nature of the complexity. This type is the most frustrating one for the patients and the physicians as well.
Why Does Prior Authorization Take So Long?
Here are some of the reasons that make the prior authorization take so long:
Incomplete Documentation
One of the primary reasons prior auths take so much time is the missing documentation and paperwork. You must know which document is necessary for the prior authorization. These documents typically include notes, lab results, reports and explanations. If either one of them is missing, you might get a delayed response.
High Volume
Insurance companies receive thousands of authorization requests daily. The insurance team can become overwhelmed easily in peak seasons like flu or the holidays. Therefore, it slows the process down significantly. Routine requests are affected more because the insurance providers spend more time on urgent matters.
Complex Policies
Insurance providers usually have a multi-layered approach towards high-cost processes and medications. More than one expert reviews these requests, and sometimes they also talk to the doctor. This approach naturally slows the process.
Provider-Side Delays
This is another problem, as we discussed earlier. The problem might come from the doctor’s side as well. If they are understaffed or overburdened, they may miss timely submissions of the requests. This mismanagement can cause delays in the approval and the patient care.
Communication Gaps
Communication gaps can also cause prior authorizations to take longer. Glitches in the system, internet problems, missed instructions, or unclear expectations can cause slowdowns. Checking mailboxes is also important in case insurers need additional documents.
Wrap Up
Prior authorization is critical, but it takes a lot of time and effort. It slows down or delays the patient care significantly. Therefore, it is important to know how long prior authorization takes in the U.S so that you can prepare well for any authorization type.
If you employ an appropriate system and strategy, you may decrease the prior authorization time to a great extent. You may also consider hiring a dedicated healthcare biller to handle the prior authorization on your behalf.
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