Legal Requirements for Prior Authorization Completion
You are not legally required to complete prior authorizations (PAs) for prescribed medications—this is an administrative requirement imposed by insurance payers, not a legal mandate. However, as a practical matter, failing to complete PAs when requested will result in your patients being unable to access their prescribed medications, creating significant barriers to care.
Understanding the Nature of Prior Authorization
Prior authorization is a utilization management tool used by managed care organizations and insurance companies, not a legal obligation for prescribers 1.
The responsibility for completing PAs typically falls jointly on the clinical team (provider, case management, and pharmacist) to ensure completion prior to discharge or medication dispensing 2.
While you are not legally compelled to complete PAs, professional and ethical obligations to your patients effectively require participation in this process to ensure they receive prescribed treatments 1.
The Administrative Reality
PA requirements create substantial administrative burden on providers, taking valuable time away from direct patient care activities 3.
Healthcare organizations often dedicate non-physician staff members solely to navigate the considerable time required for PA processes 3.
Pharmacists can play a key role in navigating insurance coverage and PA requirements, and at some institutions, pharmacists initiate and complete PAs on behalf of the clinical team 2, 4, 5.
Clinical Consequences of PA Delays
PA requirements are associated with significant treatment delays: median 31 days to treatment when PA is required versus 27 days when not required 6.
When PAs are initially denied (occurring in approximately 21% of cases), delays extend to a median of 50 days 6.
For time-sensitive procedures, delays beyond 8 weeks may negatively impact patient outcomes 3.
PA denials are associated with greater glucocorticoid exposure as patients await definitive treatment, with median exposure of 605 mg prednisone-equivalent versus 160 mg when PA is not required 6.
Introduction of new PA requirements on established drug regimens increases odds of discontinuation by 7-fold and delays next fill by approximately 10 days 7.
The Paradox of Prior Authorization
Approximately 96% of all PA requests are ultimately approved, raising serious questions about the value of this process 6.
In pediatric and adult congenital cardiology, PAs are rarely denied but nonetheless create significant administrative burden and care delays 8.
PA methodologies vary greatly among payers and regions, creating inconsistency in care delivery 3.
Parity Law Considerations
Federal mental health parity laws extend to nonquantitative limits including prior authorization, requiring that PA requirements for mental health and substance use disorder medications be no more burdensome than for medical/surgical conditions 2.
Violations persist despite parity laws: PAs are often required for generic medications for substance use disorders when generics for chronic physical diseases are not 2.
Practical Strategies to Navigate PA Requirements
Send prescriptions to the dispensing pharmacy 1-2 days prior to discharge to determine if PA is required and allow time for completion 2, 9.
Request "expedited review" of PAs when clinically appropriate—Medicare requires response within 24 hours for expedited reviews 2.
Document all steps taken in the patient's health record when navigating PA processes 4.
Do not hesitate to appeal decisions that are contrary to best patient care 4.
Engage pharmacy professionals to jointly address PA requirements, as they can navigate insurance coverage and patient assistance programs effectively 4.
Common Pitfalls to Avoid
Failing to initiate the PA process early enough, leading to treatment delays at discharge or when starting new medications 2, 9.
Not confirming that the outpatient pharmacy stocks the medication or can order it promptly, particularly for specialty medications 2, 9.
Assuming PA approval will transfer automatically when patients change pharmacies—verify the new pharmacy can access existing PA approval through the insurance system 9.
Accepting initial denials without appeal—82% of initially denied PAs are eventually approved upon resubmission with clinical documentation 2.