September 18, 2025
Majid IshakEstimated read time: 4 minutes
Every physician has been there4you’ve recommended a crucial diagnostic test for your patient, submitted the prior
authorization request, only to receive a denial or endless delays. What’s particularly frustrating is when these delays stem
from avoidable mistakes that could have been prevented with the right knowledge and processes.
Prior authorization (PA) is a cost-control mechanism that requires healthcare providers to obtain approval from insurance
companies before certain tests, procedures, or medications are covered. While intended to reduce unnecessary healthcare
spending, the system has become a significant administrative burden that affects 94% of physicians and delays care for
countless patients.
Understanding the most common pitfalls in the prior authorization process can help you navigate this complex system more effectively, ultimately getting your patients the care they need faster.
94%
Physicians Affected
Healthcare providers dealing with prior authorization burdens
$15B
Potential Savings
Expected savings over 10 years from CMS final rule
40
Weekly Requests
Average prior authorizations processed per physician weekly
Mistake #1: Incomplete or Inaccurate Patient Information
The Problem: Missing demographics, outdated insurance information, or incorrect member ID numbers are among the leading causes of prior authorization delays and denials.
Real-World Example: Dr. Sarah Chen submitted a PA request for an MRI, only to have it rejected because the patient’s insurance policy had changed from individual to family coverage three months prior. The delay cost her patient two weeks of additional pain while waiting for resubmission and approval.
Verify insurance eligibility and benefits at every patient encounter
Don't rely on annual verification 4policies change frequently
Double-check all identification numbers
Member ID numbers, group numbers, and policy effective dates must be accurate
Implement systematic verification processes
Use electronic verification systems when available to reduce human error
Mistake #2: Insufficient Medical Documentation and Justification
The Problem: Vague clinical notes, missing diagnostic codes, or failure to establish medical necessity account for a
significant portion of PA denials. Insurance reviewers need clear evidence that the requested test is medically appropriate.
Real-World Example
An internist requested a CT scan for abdominal pain but provided minimal documentation about previous treatments attempted, symptom duration, or differential diagnoses. The request was denied for “insufficient clinical information.”
Include Comprehensive Clinical History
Document current symptoms, duration, and detailed
patient history
Document Previous Treatments
Show all treatments attempted and their specific
outcomes
Provide Relevant Diagnostic Codes
Document current symptoms, duration, and detailed
patient history
Use Specific Medical Language
Demonstrate why the test is essential for diagnosis or
treatment planning
Mistake #3: Failing to Follow Payer-Specific Requirements
The Problem: Each insurance company has unique prior authorization requirements, preferred forms, and submission processes. Using a one-size-fits-all approach often leads to rejections.
Real-World Example: A cardiologist consistently used the same PA form for all insurers, not realizing that Blue Cross required additional cardiac risk stratification documentation that other payers didn’t request. This resulted in a 40% higher denial rate for Blue Cross patients.
01
Maintain Updated Payer Requirements
Create matrices for common insurers and their specific requirements
02
Use Payer-Specific Forms
Follow preferred submission methods for each insurance company
03
Stay Informed on Policy Changes
Subscribe to payer communications about requirement updates
04
Designate Insurance Specialists
Train staff members to specialize in your most common insurers
05
Leverage Electronic Systems
Use ePA systems that automatically adjust to payer requirements
Timing, Communication, and Follow-Up
Strategies
Mistake #4: Poor Timing and Communication
The Problem: Submitting requests too close to when the service is needed, or failing to communicate effectively with patients about approval status, creates unnecessary stress and potential care delays
Real-World Example:
A rheumatologist routinely scheduled MRIs before obtaining PA approval, assuming the process would be quick. When approvals were delayed, patients faced cancelled appointments and extended waits for rescheduling.
01
Submit Early
Submit PA requests as soon as clinical need is identified, not when scheduling
02
Build Processing Time
Integrate PA processing time into your scheduling
workflow
03
Communicate Proactively
Establish clear protocols with patients about
approval timelines
04
Follow Up Regularly
Track pending requests rather than waiting for
denials
Mistake #5: Inadequate Follow-Up and Appeal Processes
The Problem: Many practices lack systematic approaches to tracking PA requests and appealing denials. This passive approach means potentially appropriate tests never get approved.
Real-World Example: A family practice discovered they had a 35% PA denial rate but were only appealing 10% of those denials, missing opportunities to overturn inappropriate rejections and get patients needed care.
Implement Tracking Systems
Monitor all PA requests with regular status updates
Establish Appeal Protocols
Create systematic approaches for clinically appropriate denials
Train Staff Effectively
Develop peer-to-peer conversation techniques
Analyze Denial Patterns
Identify and address systemic issues
The Bigger Picture: Systemic Solutions
While individual practices can reduce errors, the prior authorization system requires broader reform. Recent legislation and
regulatory changes, including the CMS final rule expected to save practices $15 billion over 10 years, represent steps
toward improvement. However, physicians must continue advocating for:
Standardized PA Processes
Uniform procedures across all payers to reduce complexity and errors
Electronic Submission
Real-time decision-making capabilities to speed up
approvals
Transparent Criteria
Clear denial criteria and reasoning from insurance
companies
Reasonable Time Limits
Mandatory response timeframes for payer decisions
Moving Forward: Practical Implementation
Reducing PA delays requires both individual attention to detail and systematic practice improvements. Consider conducting a PA audit to identify your practice’s most common denial reasons, then implement targeted solutions. Remember that staff training and clear protocols are just as important as clinical documentation.
The administrative burden of prior authorization consumes valuable time that could be spent on patient care. By avoiding these common mistakes, you can navigate the system more efficiently while advocating for the systemic changes our patients deserve.
What’s your experience with prior authorization delays? Share your strategies for streamlining the approval process in the comments below, or reach out to discuss how your practice has overcome these common pitfalls.
References
- American Medical Association. (2024). Prior authorization delays care4and increases health care costs. Retrieved from
https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-delays-care-and-increaseshealth-care - American College of Physicians. (2024). Toolkit: Addressing the Administrative Burden of Prior Authorization. Retrieved
from https://www.acponline.org/advocacy/state-health-policy/toolkit-addressing-the-administrative-burden-of-priorauthorization - American Medical Association. (2024). When health plans delay and deny, they must say why. Retrieved from
https://www.ama-assn.org/practice-management/prior-authorization/when-health-plans-delay-and-deny-they-mustsay-why - CoverMyMeds. (2024). 7 Common Prior Authorization Hurdles and How to Overcome Them. Retrieved from
https://insights.covermymeds.com/healthcare-technology/prior-authorization/common-prior-authorization-hurdlesand-how-to-overcome-them - AKASA. (2025). 7 Prior Authorization Challenges and How To Overcome Them. Retrieved from
https://akasa.com/blog/prior-authorization-mistakes/ - Staffingly. (2025). Common Reasons Prior Authorization Gets Denied in Healthcare. Retrieved from
https://staffingly.com/common-reasons-prior-authorization-gets-denied-in-healthcare/ - American Medical Association. (2025). Fixing prior auth: Nearly 40 prior authorizations a week is way too many.
Retrieved from https://www.ama-assn.org/practice-management/prior-authorization/fixing-prior-auth-nearly-40-prior-authorizations-week-way
