7 Common Prior Authorization Hurdles and How to Overcome Them

When a provider prescribes medication during an office visit, a process is set in motion to get the patient their medication. Often, this process involves a prior authorization (PA) request, especially if it’s for a complex treatment or prescription.

It’s true that PA can be time consuming for providers and pharmacists, but, ultimately, the goal is to improve patient outcomes by making sure they get the right medications without incurring unnecessary additional costs.

Sometimes, though, the traditional PA process requires pharmacists, providers and health plans to exchange a series of phone calls and faxes, which can delay patients from getting their medications. The 2022 Medication Access Report found that 21% of patients experienced a delay in receiving medication over the last 12 months due to PA.

Delays can occur for many reasons, including extended back and forth communication between providers and pharmacists and reliance on phone calls and faxes. Below, we outline common holdups providers, pharmacists and patients may face when PA requests are delayed, and what can be done to help circumvent hurdles delaying patients from beginning therapy.

Seven common reasons PA requests are denied

A PA may be denied for a treatment or medication for many reasons, but some are more common and, fortunately, easier to address. Below are the six most common reasons for PA denials.

Reason 1: Cost management

To help as many patients as possible get the medications they need, including those who need more expensive ones, health plans look for ways to conserve funds. How? Many have substantiation requirements on PA’s that favor less expensive medications that are just effective, like generics.

Reason 2: Questions regarding medical necessity

A PA request is typically required for more costly, complex treatments. Medical necessity applies to clinical situations and is the lens payers use to evaluate whether a treatment meets the generally accepted medical standards for that condition. If the proposed treatment doesn’t meet the threshold for being medically necessary, it won’t be reimbursed by the payer.

Reason 3: Administrative errors

If a provider’s office submits a wrong billing code, misspells a name or makes another clerical error, this can result in a denied PA request.

Reason 4: The requested service or device isn’t covered

This is common for procedures like cosmetic surgery or treatments not approved by the FDA. Another reason can be that a prescribed device isn’t covered by pharmacy benefits, which means that a PA must be submitted to the patient’s medical benefits. For example, while a prescription for insulin may be covered by pharmacy benefits, other items, such as test strips or an insulin pump, could be covered under the patient’s medical benefits. In cases like this, two PAs must be submitted — one to pharmacy benefits and the other to medical benefits.

Reason 5: Missing details

When a PA request has insufficient information about why the medication or treatment is needed, it can be denied.

Reason 6: Procedural errors

For example, a health plan may require a PA request for a particular non-emergency test. If the patient completes the test before it’s been approved, the payer can deny payment — even if the test was really needed.

Reason 7: Patient hasn’t tried and failed other medications

Insurance plans often require providers to have their patients try and fail certain medications or treatments before they approve the next option, which may be more expensive. For example, a patient suffering from migraine headaches may have to show that over-the-counter pain medications like acetaminophen or ibuprofen were tried and didn’t work.