“Doctor, your medication needs approval first.” 

That single sentence can delay treatment for days—even weeks—and for many patients, that delay comes at a high cost: worsening conditions, exacerbating suffering, and inviting ER visits.

The culprit? Prior authorization! 

It is true that PA is supposed to manage costs and ensure appropriate care, but in today’s scenario, it has turned out to be a major roadblock rather than a formal checkpoint. However, an expert prior authorization service can actually change the whole ballgame.

Let’s dig deeper into the present state of prior authorizations, understand the vital challenges you should be aware of, and how an expert solution provider helps you navigate those challenges.

What’s Broken in Prior Authorization—and Who’s Trying to Fix It?

In recent years, state and federal policymakers have turned their attention to fixing the tangled web of prior authorization (PA). Why? Because the process — originally designed to curb unnecessary healthcare expenses — has now become one of the biggest sources of delayed care, denied coverage, and administrative headaches.

A recent AMA survey revealed the hard truth: Prior authorization, more often than not, blocks access to lifesaving treatments. Physicians nationwide are reporting that this process is harming patients, causing practice overload, and burning out their staff.

To address this, more than 60 health insurers, including giants like AHIP and the Blue Cross Blue Shield Association, have stepped forward with a commitment to reform. But here’s the catch: these reforms are voluntary. Unfortunately, the prior authorization process still remains costly, inefficient, opaque, and too often, hazardous for patients.

Insurers have recently proposed six major changes to streamline the process. On paper, they sound promising:

Related Reading: The Hidden Cost of Access: Rethinking Prior Authorization

The 6 Vital Reforms that Aim to Fix Prior Authorization

1. Standardizing Electronic PA submissions using Fast Healthcare Interoperability Resources (FHIR) APIs.
2. Reducing the scope of PA for fully insured plans and ACA/Medicare Advantage policies.
3. Honoring Prior Authorizations across plans during a 90-day transition when patients change insurance.
4. Improving denial communication with clear language and easier-to-follow appeals.
5. Providing real-time responses for at least 80% of electronic prior auth submissions.
6. Ensuring licensed clinician review for denials based on medical necessity.

The goal is to make prior authorization faster, more transparent, and less painful for everyone involved.

Let’s talk about the reality on the ground. The prior authorization process is still a big burden for major healthcare providers in the U.S. These are the top 7 challenges.

Related Reading: Saving Yourself from Prior Authorization Heartache!

Where It Hurts: The Core Challenges of Prior Authorization

High volume of prior auth requests: 

On an average, physicians deal with almost 41 prior authorizations every week, eating up almost 48 hours per week. The whole process hampers your patient care while overburdening your staff.

Ever-changing payer policies: 

Payer rules are frequently changed, and even in the single plan, you need different paperwork to document different services. Healthcare providers often face difficulties in understanding the current updates, thus causing unnecessary confusion, delays, and denials. A professional solution keeps up with these changes in real time and helps reduce errors.

Opacity of the process: 

A 2021 AMA study found that 62% of doctors have trouble figuring out if a service needs prior authorization. Some payer portals are helpful, but others make it hard to find that information. Many times, staff have to call or fax just to check. This confusion causes delays, extra work, and more denials.

Tedious nature of work: 

Submitting a prior authorization takes over 12 minutes on average, and even longer if it gets rejected and needs to be done again. Many providers still use phone, fax, or paper, which often leads to lost faxes and slow replies. Every step takes time, follow-up, and rework. A better solution uses automation and electronic tools to cut the time by up to 70%.

Substantial administrative burnout: 

Burnout is a common thing in the healthcare domain and PA only contributes more to that. Almost 88% of physicians admitted that the PA workload is too much for them, while 93% of workers feel overwhelmed with the administrative hassles related to the process. Many feel that PA is making their job more arduous instead of helping them.

Eligibility and coverage gaps: 

Patient data always plays a vital role in the prior authorization process, and you can face PA delays and rejections if you miss or use incorrect patient data. You can also face a slowed-down process because of using old forms.

Outdated technology: 

A study shows that only 26% of prior authorizations are fully electronic. Many organizations still don’t have the tech to check requirements early. Manual systems cause errors, repeat work, and information loss. Switching to electronic prior auth can save about 17 minutes per request.

The good thing is that a practice does not necessarily have to go through all these hassles. A professional prior authorization company can help you with all these challenges. The following are the ways –

How a Professional Prior Authorization Expert Solves It All

A professional prior authorization service handles everything from checking patient eligibility to submitting requests and managing denials. This means fewer delays, no missed deadlines, and more approvals. These services also know the rules for each payer and keep up with real-time changes, helping you avoid errors, reduce rework, and improve approval rates. They use advanced tools and AI to process requests quickly, saving time and cutting down on manual work. You also get real-time updates and tracking.

A professional company makes your payer communication clear and timely, thus ensuring a seamless PA follow-up and appeal process. Your team can therefore focus more on clinical care and feel less overwhelmed with the right outsourced prior authorization service partner. Overall, this leads to faster payments, fewer write-offs, and a stronger revenue cycle for your practice.

So, are you now finally considering outsourcing your prior authorization process to the right partner? Look nowhere else than SunKnowledge Inc.

Related Reading: How To Upgrade Your Prior Authorization Process

SunKnowledge: The Ideal Prior Authorization Solution Partner

At SunKnowledge, we know how frustrating prior authorization can be. From endless paperwork to long approval times, the process often delays patient care and hurts your revenue and we offer a smarter solution here. Our holistic solution saves time, reduces denials, and keeps your practice running smoothly.

Our team is trained to handle 38–40 prior authorization requests per person per week, helping you manage the high volume with ease. We use industry-leading electronic prior authorization (ePA) platforms to ensure fast, accurate submissions and prompt approvals. No more faxing, making phone calls, or waiting around.

We’ve also taken real steps to improve the process. For example, SunKnowledge recently implemented a process improvement initiative for a Home Medical Equipment (HME) client with multiple locations. This client faced serious issues like missed credit adjustments and incorrect reason selections, which caused revenue loss and compliance problems. Using internal audits, workflow reviews, and focused training, our team cut missed adjustments by 46% in just one week and raised accuracy from 57% to 87% in key regions.

But we don’t stop at just prior auth. We offer end-to-end RCM services, along with virtual assistance and medical scribing, helping your staff provide the best clinical care while we handle the rest.

Let SunKnowledge be your trusted partner in creating a faster, smarter, and more reliable prior authorization process.