When a doctor says “we need insurance approval before we can start” that’s prior authorization. It’s a formal sign-off from the insurance company confirming that a treatment, medication, or procedure is covered before it happens.
The process itself makes sense. The execution is where things break down.
According to the AMA, 94% of physicians report that prior authorization delays have directly affected patient care. In 2026, with more services requiring approval and payer rules growing more complex, the burden on healthcare practices is only increasing.
Why Prior Authorization Is Getting Harder in 2026
A new CMS rule now requires Medicare Advantage and most Medicaid plans to process urgent PA requests within 72 hours and standard requests within 7 calendar days. That’s a meaningful policy shift but it only helps if submissions arrive complete and accurate on the first attempt.
Most practices aren’t there yet. The challenges below explain why.
The Most Common Prior Authorization Challenges and How to Fix Them
1. Slow Approvals That Delay Patient Care
Standard PA requests can take anywhere from 2 days to 3 weeks depending on the payer and service type. During that window, patients wait sometimes for urgent medications, sometimes for surgeries already on the schedule.
The biggest driver of slow approvals is incomplete submissions. When documentation is missing or formatted incorrectly, insurers flag the request for manual review, which adds days. Practices that have moved to structured electronic submissions through proper EDI enrollment report faster turnaround because requests arrive clean and complete.
2. Denials Caused by Documentation Errors
A wrong diagnosis code, a missing referral, an outdated clinical note any of these can get a request rejected before a reviewer even reads it. The service itself would have been approved. The error was administrative.
This is one of the most preventable challenges. Understanding what authorization in medical billing actually requires and building a submission checklist around those requirements eliminates most of these errors before they happen.
Common documentation mistakes that cause PA denials:
- Incorrect or mismatched ICD-10 diagnosis codes
- Missing clinical notes supporting medical necessity
- Outdated referral or authorization numbers
- Submitting to the wrong payer or plan type
- Incomplete patient history in the request
3. Every Payer Has Different Requirements
There is no universal prior authorization rulebook. Aetna’s requirements differ from UnitedHealthcare’s. Medicare Advantage plans vary by region. Commercial payers update policies quarterly sometimes without direct notice to providers.
For a practice managing 10 to 15 different payers, staying current is effectively a separate job. Missing one policy update can trigger a wave of rejections that takes weeks to resolve.
The practical answer is maintaining payer-specific submission checklists and updating them whenever coverage terms change ideally before claims go out, not after denials come back.
4. High Administrative Burden on Staff
The AMA reports that physicians and their teams spend an average of 13 hours per week on prior authorization tasks alone. That’s time taken away from patient care and a significant contributor to billing staff burnout.
This is where prior authorization management as a dedicated function separate from general billing makes a structural difference. When one person or team owns authorization tracking end-to-end, submissions are more consistent and follow-ups happen on schedule.
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TALK TO AN EXPERT5. Vague Denial Reasons That Make Appeals Difficult
“Not medically necessary” is one of the most common denial reasons and one of the least actionable. Without a specific explanation, preparing a targeted appeal is guesswork.
The most effective appeals directly address the stated denial reason with additional clinical documentation. Tracking denial patterns by payer and service type also helps if a particular insurer is consistently denying a specific procedure, the submission process needs to change, not just the appeal. This is where structured denial management goes beyond individual cases and improves the overall first-pass approval rate.
6. No System for Tracking Pending Requests
Many practices submit a PA request and have no reliable way to monitor its status. They don’t know if the insurer needs more information, whether the request was already decided, or whether an authorization is about to expire.
Expired authorizations have to be resubmitted from scratch. Missed follow-up windows mean unnecessary delays. A basic tracking system whether through billing software, a clearinghouse, or a dedicated workflow prevents most of this.
How These Challenges Connect to the Broader Revenue Cycle
Prior authorization doesn’t sit in isolation. It’s one part of a larger billing workflow and problems upstream tend to create problems downstream.
| Stage | Common Problem | Impact on PA |
| Insurance verification | Coverage not confirmed before appointment | PA submitted to wrong payer or plan |
| Medical coding | Wrong diagnosis or procedure codes | Request denied on submission |
| EDI submission | Paper-based or incomplete electronic claim | Delays in payer review |
| Denial management | No structured appeals process | Revenue lost on overturnable denials |
| RCM automation | Manual tracking across multiple payers | Missed follow-ups, expired authorizations |
Confirming coverage details through insurance eligibility verification before each appointment is often where the chain breaks first. Submitting a PA under the wrong plan type means starting over entirely.
On the technology side, AI-driven revenue cycle tools are increasingly being used to flag missing documentation before submission, track authorization status across payers in real time and surface patterns in denial data. These aren’t replacements for experienced billing staff they handle the routine checks so staff can focus on cases that need judgment.
Summary
Prior authorization volume is growing, payer rules are not getting simpler and the 2026 CMS timelines only help practices that are already submitting clean, complete requests. The practices managing PA well in 2026 share a few things: they verify coverage before submitting, they use structured electronic submissions, they track every open request and they treat denials as data not just setbacks.
The practices that aren’t doing those things are spending 13 hours a week finding that out the hard way.
If managing that workload internally isn’t realistic for your practice, MedLife MBS handles prior authorization end-to-end from submission and tracking to appeals so your team can stay focused on patient care.