How to Speed Up Prior Authorization for Medication?

Every year, millions of Americans wait – sometimes dangerously longer – for their insurance agencies to approve a medication their physicians already suggested. Here is what you can do about it.

Prior Authorization (PA) is a cost control process used by health insurers that requires your doctor to get approval before you can fill a prescription. On paper, it sounds reasonable. In some practices, it is one of the biggest sources of frustration and medical harm in the American healthcare system. The American Medical Association’s 2023 Prior Authorization Physician Survey found that the average medical practice completes 45 prior authorization requests per doctor per week, consuming nearly two business days of physicians’ and staff time. 

The good news? There are focused, proven steps you can take to leave that timeline. This instruction walks through everything.

Understand Exactly Why PA is Being Requested

Before you can battle a delay, you need to understand the reason behind it. Prior authorization can be triggered for multiple causes: the drug is on a non-preferred tier, it needs proof that cheaper alternatives were tried first, or it’s flagged as experimental or off-label.

Understanding the accurate difference between what’s submitted and what is needed lets your physician’s office address the reactions – instead of resubmitting blindly.

Have Your Doctor’s Office Submit a Complete, Addressed Request

Incomplete or some generic Prior authorizations are the single most common causes approvals are delayed or denials. Insurers get thousands of requests, and feedbackers watch for some specific medical language tied to their coverage criteria.

• Ask your doctor to reference the insurer’s own medical suitability in the letter of clinical essentials – not just general clinical instructions.
• Involves documentation of step therapy flop if the insurer needs medications to have been tried. Lab results, pharmacy records, and doctor notes all count.
• Usage of the correct diagnostic codes (ICD-10) and drug codes (NDC/HCPCS). Coding mismatches: reasons for automatic delays.
• Submit through the insurer’s electronic portal rather than fax when possible – electronic submissions are processed an average of 69% quicker, per CMS data.

Request an urgent or expedited review immediately.

Under federal law and most state rules and regulations, insurers are needed to make expedited determinations – generally within 72 hours – when a standard timeline would seriously affect your health. You do not have to be in the ER to qualify.

Have your doctor write why a delay would seriously harm – worsening of a progressive situation, chances of hospitalization, or inability to function. This language addresses the expedited method. Insurers that violate these timelines can face state regulatory actions.

Ask your pharmacist to help – they understand the system

Pharmacists are underused allies in the Prior Authorization method. Many have direct relationships with insurers’ PA experts and understand accurately which drugs have formulary alternatives that skip the authorization method completely.

In addition, large retail pharmacy chains such as CVS and Walgreens have devoted PA coordinators who can adhere up directly with insurer PA sections. A step that often moves the method more quickly than a doctor’s office call.

Contact your insurer’s PA department directly – in writing

Most individuals do not go directly to call the insurer themselves, but rather their physician’s office. A brief, factual written request from you can sometimes accelerate the internal routing of your condition.

1. Write a one-page letter stating your name, member ID, the medication, your diagnosis, and the date the PA was submitted.
2. Include a sentence from your doctor describing the clinical urgency – even if informally stated in an email you print and attach.
3. Send it through certified mail and hold the receipt. This creates a paper trail that matters if you later file a complaint with your state insurance commissioner.
4. Adhere by phone every 48 hours, log the date, time, rep name, and what was said.

The prior authorization system was designed to prevent unnecessary treatment — but it has evolved into a barrier to necessary treatment. 

Use patient assistance programs while you wait.

You must not have to go without supplements while the insurance bureaucracy moves slowly. Multiple pharmaceutical manufacturers offer free or low-cost bridge supplies directly to individuals who are in the PA method.

File an internal appeal – then an external one

A denial is not the end of the road. Under the Reasonable Care Act, all health plans should offer at least one level of internal appeal and access to an independent external review. External reviews are decided by independent medical experts – not the insurer’s own staff – and are set by the plan.

When writing your appeal, include a letter from your physicians describing the medical necessity in plain language, citations to published medical instructions (AHA, ADA, NCCN, etc). Supporting the procedure and any peer-reviewed studies related to your situation. The appeal reviewers are seeking medical evidence, not emotion.

Escalate to your state insurance commissioner.

Each state of the United States has an insurance commissioner or a section of insurance that regulates health plan conduct. Filing a complaint is free, takes about 20 minutes online, and puts real pressure on insurers – they are needed to react to the commissioner within a set timeframe and risk fines for non-compliance.

Find your state’s compliant portal at the National Association of Insurance Commissioners (NAIC) website at naic.org. Multiple states also have a Consumer Assistance Program (CAP) that will instruct you through the method at no cost.

Know what’s changing – the regulatory landscape is shifting

In January 2024, CMS finalized a landmark rule requiring Medicare Advantage and Medicaid managed care plans to make PA decisions within 72 hours for urgent cases and 7 calendar days for standard cases. The rule also requires plans to share PA data publicly, raising transparency and accountability.

Multiple states – involving Texas, Arkansas, Colorado, and New York – have passed gold carding laws that exempt physicians with high approval rates from repeated PA needs for the same drug or process. If your physician qualifies for gold carding under your state’s law, ask them to check with your insurer directly.

Conclusion – You are not the only one in this battle!

Prior Authorization delays are a systemic issue – not a personal failure. The method is intentionally complicated, and insurers rely on individual attrition. But with the right details, the right documentation, and persistence, you can and do win these battles. Individuals who advocate for themselves – or have someone advocate on their behalf – persistently notice quick outcomes.

If you are controlling a serious or severe condition, consider connecting with a patient advocacy firm specific to your diagnosis. Groups like the Patient Advocate Foundation offer free case management services that specialize in insurance disputes and can do much of this work alongside you.

Need Help Navigating Prior Authorization? Book us Today!

Healthcare paperwork and insurance approvals can be complex and time-consuming. Our skilled patient advocacy team supports individuals:

• Know insurance needs.
• Record prior authorization requests.
• Prepare supporting documentation.
• Coordinate with healthcare providers.
• File appeals and complaints.
• Access patient assistance programs.

Whether you are facing a medication delay, procedure denial, or insurance challenge, we are here to support you, guiding you through the process. Contact DocVaz today and let us help you get the care you require without unnecessary delays in Medical Billing Services.

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