What are the consequences of delays in prior authorization (PA) for medical procedures, Durable Medical Equipment (DME), and imaging?

Consequences of Prior Authorization Delays for Medical Procedures, DME, and Imaging

Prior authorization delays for medical procedures, DME, and imaging can limit patient access to appropriate care, potentially leading to higher costs through delayed diagnosis, layered testing approaches, and negative impacts on patient outcomes.1

Impact on Patient Care and Outcomes

• Delays in prior authorization can limit patient access to appropriate imaging procedures and medical interventions, potentially compromising quality of care 1
• Prior authorization delays for medical procedures can range from 2 weeks to several months, with 73% of patients reporting delays of 2 or more weeks 2
• In a survey of cancer patients, 22% did not receive the care recommended by their treatment team due to prior authorization delays or denials 2
• Delays in diagnosis resulting from prior authorization requirements can direct patients to higher-cost diagnostic approaches through layered testing 1
• For time-sensitive procedures, delays beyond 8 weeks may negatively impact patient-important outcomes 1

Administrative Burden and Resource Utilization

• Prior authorization processes require significant administrative time from providers, taking valuable time away from patient care activities 1
• Provider employees report spending time equivalent to more than 100,000 full-time registered nurses per year on prior authorization tasks 3
• For total joint arthroplasty, the mean time to approval was 26.3 days for hip replacements and 33.7 days for knee replacements 4
• Healthcare providers often need to dedicate non-physician staff members solely to navigate the considerable time required for prior authorization processes 1
• 67% of patients report having to personally become involved in the prior authorization process, with 20% spending 11 or more hours dealing with prior authorization issues 2

Clinical Consequences of Delays

• For infusible medications in rheumatology, prior authorization requirements were associated with treatment delays (median 31 days vs 27 days without prior authorization) 5
• Patients whose prior authorizations were initially denied experienced even longer delays (median 50 days) and greater prednisone-equivalent glucocorticoid exposure in the following 3 months 5
• In cardiac care, prior authorization delays may compromise time-sensitive interventions for conditions like ST-elevation myocardial infarction (STEMI), where timely treatment is critical 1
• For gastrointestinal procedures, delays beyond 8 weeks for time-sensitive indications may negatively impact patient outcomes 1
• In obstetric care, prior authorization delays can impede access to necessary ultrasound imaging, potentially affecting maternal and fetal health outcomes 6

Psychological Impact and Trust in Healthcare

• Prior authorization-related anxiety is significantly higher than usual anxiety levels for patients (mean score 74.7 vs 37.5) 2
• After experiencing prior authorization processes, 89% of patients reported trusting their insurance company less, and 83% trusted the healthcare system less 2
• Patient involvement in the prior authorization process was associated with increased odds of distrusting their insurance company and the healthcare system 2
• The overall prior authorization experience was rated as "bad" or "horrible" by 72% of patients 2

Inefficiencies in the System

• Despite high denial rates initially, 96% of prior authorizations for infusible medications were ultimately approved, questioning the value of the process 5
• For total joint arthroplasty, only 0.4% of hip replacement and 0.3% of knee replacement prior authorization denials were upheld after the complete process 4
• Prior authorization methodologies vary greatly among payers and regions of the country, creating inconsistency in care delivery 1
• Prior authorization frequently relies on proprietary algorithms that may be inconsistent with published literature and clinical guidelines 1

Recommendations to Mitigate Delays

• Healthcare organizations should establish dedicated teams to navigate the prior authorization process, particularly for complex or time-sensitive cases 1
• Payors and providers should consider alternative coding systems for procedures requiring prior authorization to better account for the administrative burden 1
• Managed care organizations should minimize burdens placed on providers and patients when administering prior authorization requirements 1
• Streamlining overlapping requirements between prior authorization and other administrative processes would benefit both providers and payors 1
• Artificial intelligence may offer potential solutions, with 65% of private payer respondents planning to incorporate AI into the process in the next 3-5 years 3