7 Common Prior Authorization Hurdles and How to Overcome Them
Prior authorization request denials can sometimes cause a lot of frustration for healthcare provider teams and can lead to delays in patients’ access to medication. Here are some common causes of prior auth denials and tips for avoiding them with electronic prior authorization.
When a provider prescribes medication, a process is set in motion to get the patient their medication. Often, this process involves a prior authorization request, especially for complex specialty treatments administered in a physician’s office or hospital setting.
Insurance plans use prior authorization requests to determine coverage and verify the clinical necessity of one drug versus another. When a prior auth is required for a prescription medication, providers or their staff must fill out a request form and submit it to the insurer or pharmacy benefit manager (PBM) for a determination.
For care team members, such as medical assistants and nurses, managing prior auth requests can be one of the most time-consuming parts of their day. A 2023 survey by the American Medical Association found that healthcare practices complete an average of 43 prior authorizations per physician each week.2023 AMA prior authorization physician survey Additionally, a survey of 1,000 providers by CoverMyMeds found that more than half said they don’t have enough time to complete them.CoverMyMeds Provider and Pharmacist Surveys, 2022 This process can be expedited by submitting prior auths electronically.
HELP TO REDUCE PRIOR AUTH DENIALS WITH ELECTRONIC PRIOR AUTHORIZATION
Prior authorization denials create just one more barrier between patients and the medication they have been prescribed. Simple errors such as leaving fields blank, misspellings or failure to follow payer requirements are common reasons for denials that can be reduced with electronic prior authorization (ePA) solutions.
Instead of relying on outdated fax and phone methods, ePA enables providers and their staff to manage pharmacy-initiated prior auth requests and proactively initiate prior auth requests electronically at the point of prescribing. This can be done within their existing workflow, either through an online portal or through an electronic health record (EHR) integration.
Seven common reasons PA requests are denied
1. COST MANAGEMENT
Health plans strive to help patients access the medications they need, while managing costs responsibly. This may involve prior auth requirements that encourage the use of equally effective, lower-cost alternatives, such as generics.
ePA solutions can help providers, medical assistants, nurses and other care team members by providing visibility into patient’s benefits information and prior auth requirements at the point of prescribing.
2. QUESTIONS REGARDING MEDICAL NECESSITY
A prior auth request is typically required for more costly, complex treatments. Medical necessity is the criteria payers use to evaluate whether a treatment meets the accepted medical standards for that condition.
If the proposed treatment doesn’t meet the criteria for being medically necessary, it won’t be reimbursed by the payer. Healthcare teams often face challenges in providing proof of therapy necessity, determining patient’s insurance coverage and completing complex forms.
As more payers require prior auth for GLP-1 drugs, providing proof of medical necessity for these popular drugs is becoming an especially time-consuming task for healthcare teams. When your ePA solution is integrated with EHRs, the necessary documentation showing that a patient has tried and failed other medications can be processed more quickly and efficiently.
3. ADMINISTRATIVE ERRORS
A denied prior auth request can occur when a provider’s office submits a wrong billing code, misspells a name or makes another clerical error. Requests can also be denied if the prior auth request lacks sufficient information about why the medication or treatment is needed.
When integrated with EHRs, ePA solutions can automatically populate necessary fields in prior auth requests, reducing manual entry and minimizing errors. Your ePA solution should guide users through the correct forms and ensure all necessary fields are completed, reducing the likelihood of denials due to missing or incorrect information.
Quick Guide to Electronic Prior Authorization Requests with CoverMyMeds Looking for help completing ePA requests? If you haven’t done one before, you’ve done one wrong, or you started and gave up, read this quick guide for healthcare providers and office staff.
4. PROCEDURAL ERRORS
A health plan may require a prior auth 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.
It’s important to have visibility into all the prior auth requirements that can impact the patient within the process of diagnosis and confirmation, but requiring your team to memorize every requirement for every plan is not realistic.
5. THE REQUESTED THERAPY REQUIRES MULTIPLE PRIOR AUTH REQUESTS
Prior auth requests are often denied when a prescribed device isn’t covered by pharmacy benefits, which means that a prior auth request 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 a continuous glucose monitor (CGM) and an insulin pump, should also be covered under the patient’s medical benefits. These devices themselves often have multiple components, like a sensor and a transmitter in two separate prescriptions, which can only be approved if prescribed in conjunction with one another. In other cases, relatively inexpensive items like test strips and hypodermics may be fully covered and free to the patient if they have a prescription but must be paid for in full by the patient without one.
In cases like these, multiple prior auth requests must be submitted — for instance, one to pharmacy benefits and another to medical benefits.
6. 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. This issue is also frequently seen with GLP-1 prior auths for weight loss.
ePA integration with EHRs makes it easier for providers to include all relevant patient history and medication trial information directly from the patient's medical records. This means the necessary documentation showing that a patient has tried and failed other medications can be processed more quickly and efficiently and reduces the possibility of manual errors in coding.
7. PRESCRIBED MEDICATIONS ARE NON-FORMULARY
If a medication is not included in the insurance company's approved list of covered drugs, the prior auth request for the prescription will be denied. Payers typically update their formulary annually, with major changes taking effect on January 1 of each year.
However, formulary updates can also happen throughout the year, making it difficult for providers to keep track of what medications are covered by a particular patient’s insurance. Using an ePA solution that integrates with EHRs can make it easier for providers to adapt to formulary changes without disrupting patient care, as well as have better visibility into medications covered by the patient’s plan. (Read about 5 ways care teams are navigating 2025 health benefit changes.)
Simplify GLP-1 Prior Authorization with CoverMyMeds
Struggling with prior authorizations for GLP-1 drugs? Read "Simplify GLP-1 Prior Authorization with CoverMyMeds" to discover how electronic prior authorization with CoverMyMeds can help healthcare teams save time and ensure all necessary prior auth request fields are completed.
Overcome prior auth barriers with CoverMyMeds
Manual procedures and outdated workflows can create barriers for patients to access their medication in a timely and affordable manner. CoverMyMeds offers electronic prior authorization solutions that help break down these barriers and make the prior auth process more efficient. Our ePA solutions are available through our easy-to-use platform and are connected with more than 350 EHRs, allowing providers to complete prior auth requests within their existing workflow.
CoverMyMeds’ solutions work for all drugs, including specialty medications, and all health plans and PBMs, including Medicare Part D and Medicaid. Our digital solutions, including ePA and specialty patient support services, are available at no cost to prescribers and their staff.
Beyond simplifying the cumbersome prior authorization process, CoverMyMeds has built an expansive suite of tech-enabled solutions to help solve some of the most common medication access and affordability challenges faced by patients. Our network connects providers, pharmacies, pharmaceutical companies and payers to help patients get the medicine they need to live healthier lives.
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