Prior authorization delays the care your patients need by an average of nine days. For the physicians managing those requests, it consumes 13 hours a week in documentation, payer calls, portal entry, and follow-up. This report breaks down the volume, cost, and operational impact of prior authorization on small and midsize outpatient practices.
Key Takeaways
- Physicians complete an average of 39 prior authorization requests per physician each week, according to the AMA’s 2024 prior authorization survey.
- Practices spend approximately 13 hours per physician per week managing prior authorization tasks.
- Prior authorization can delay care. Physicians report that delays are common, and one cited average treatment delay is approximately 9 days for affected cases.
- Denial rates vary by payer type, but first-submission denial rates can range from 16% to 28% in some settings.
- Most denials are not appealed, even though appealed denials are often overturned. Medicare Advantage data show that only about 11.5% to 12% of denied requests are appealed, while more than 80% of appealed denials are partially or fully overturned.
Key Findings
| Finding | Summary |
|---|---|
| 39 prior authorization requests per physician weekly | Physicians average 39 prior authorization requests each week, per the AMA’s 2024 prior authorization survey. |
| 13 staff hours per physician per week | Practices spend approximately 13 hours per physician per week managing prior authorization tasks. |
| Average treatment delay of approximately 9 days | Physicians report an average delay of approximately 9 days for prior authorization-affected cases. |
| First-submission denial rates of 16% to 28% | Denial rates vary by payer, with first-submission denial rates ranging from 16% to 28% in some settings. |
| Most denials go unappealed despite high overturn rates | Only about 11.5% to 12% of denied Medicare Advantage requests are appealed, while more than 80% of appealed denials are partially or fully overturned. |
Scope of the Prior Authorization Problem
Prior authorization now stands between nearly every clinical decision and the care that follows it. The volume has grown far beyond what the process was originally designed to handle, and practices are absorbing most of the cost.
Prior Authorization Volume and Administrative Burden
| Metric | Finding | Source or Basis |
|---|---|---|
| Medicare Advantage prior authorization determinations in 2024 | Nearly 53 million | KFF analysis of CMS data |
| Average prior authorization requests per physician per week | 39 | AMA 2024 Prior Authorization Survey |
| Average staff hours spent on prior authorization per physician per week | 13 hours | AMA 2024 Prior Authorization Survey |
| Physicians with staff working exclusively on prior authorization | 40% | AMA 2024 Prior Authorization Survey |
| Physicians who say prior authorization somewhat or significantly increases burnout | 95% | AMA 2024 Prior Authorization Survey |
| Estimated annual U.S. administrative spending connected to prior authorization | Approximately $35 billion | NIH/PMC-cited research |
| Estimated annual U.S. administrative spending connected to prior authorization | Approximately $68,000 | ReferralMD analysis of AMA data |
- At 39 requests per physician per week, prior authorization is no longer a minor administrative task. It is a recurring workflow that requires staff time, payer-specific knowledge, documentation management, and regular follow-up.
- For a two-physician practice, this volume may represent nearly 80 prior authorization requests each week. For a four-physician practice, the workload may exceed 150 requests weekly. Without dedicated support, this work often falls across front desk staff, medical assistants, nurses, billers, and providers.
Prior Authorization Processing Times
Processing times vary by payer, service type, documentation quality, and whether the request is standard, urgent, or appealed. Even when a request is ultimately approved, the time required to gather information, submit documentation, follow up with the payer, and wait for a decision can delay care.
Processing Times by Request Type
| Request Type | Typical Days to Decision | Common Notes |
|---|---|---|
| Urgent or expedited requests | 24 to 72 hours | Timelines depend on payer rules, request category, and federal or state requirements. |
| Standard imaging, such as MRI, CT, or PET | 3 to 7 days | Imaging is among the most common service categories requiring prior authorization. |
| Standard medical procedures | 3 to 7 days | Timing varies by payer and completeness of documentation. |
| Oncology treatment approval | Median of approximately 5 days | Published oncology research has reported multi-day authorization timelines. |
| Oncology treatment denial | Median of approximately 6 days | Denied requests may take longer because of additional review requirements. |
| Specialty drugs with step therapy | 7 to 14 days | Step-therapy requirements can add time before approval. |
| Behavioral health services | 5 to 10 days | Requirements vary by payer, plan, and state parity rules. |
| All prior authorization requests with affected treatment | Average delay of approximately 9 days | NIH-cited research and related reporting. |
| Prior authorization-related delays lasting one week or more | Approximately 24% of affected cases | JAMA Network Open-cited findings. |
- Prior authorization delays are not limited to complex specialty care. Imaging, routine procedures, medications, and behavioral health services can all be affected.
- For practices, this means delays can appear throughout the schedule, including canceled procedures, postponed diagnostic workups, rescheduled visits, and additional patient calls.
- For patients, even a short delay can have consequences. A 3- to 7-day delay may affect diagnosis, treatment planning, symptom control, medication adherence, and confidence in the care process.
- In more complex cases, such as oncology or specialty drug therapy, delays may carry greater clinical and emotional weight.
Prior Authorization Denial Rates
Denial rates vary by payer type, service category, and how complete the submission is. The table below breaks down denial and appeal rates across Medicare Advantage, commercial plans, and Medicaid managed care.
Denial Rates by Payer Type
| Payer Type | Average Denial Rate | First-Submission Denial Rate | Share of Denials Appealed | Appeal Overturn Rate |
|---|---|---|---|---|
| Medicare Advantage | Approximately 7.7% | Approximately 6.4% | Approximately 11.5% to 12% | Approximately 81.7% |
| Commercial or private plans | Approximately 12% | 16% to 28% | Varies by payer and practice | Approximately 41% |
| Medicaid managed care | Approximately 12% | Can exceed 25% in some plans | Varies by plan | Varies by plan |
| Overall cross-payer estimate | Approximately 12% to 15% | 16% to 28% | Often low | Approximately 41% to 82% |
- Medicare Advantage data show that a relatively small share of denied requests are appealed, yet a large share of appealed denials are overturned.
- This suggests that many denials may be addressable when practices have the time, documentation, and follow-up capacity to pursue them.
- For small practices, the challenge is the time required to gather records, write appeal language, track deadlines, contact payers, and follow through while continuing to manage daily patient care.
Prior Authorization Time Burden
Prior authorization requires more than submitting a form. The full workflow may include chart review, benefit verification, clinical documentation, payer portal entry, phone calls, faxes, status checks, peer-to-peer scheduling, denial review, appeals, and patient communication.
| Metric | Finding |
|---|---|
| Average prior authorization requests completed per physician per week | 39 |
| Average staff hours spent on prior authorization per physician per week | 13 hours |
| Equivalent business days consumed per week | Approximately 1.5 to 2 business days |
| Physicians reporting that prior authorization somewhat or significantly increases burnout | 95% |
| Physicians reporting that prior authorization delays patient access to necessary care | 94% |
| Physicians reporting that patients abandon treatment due to prior authorization burden | 78% |
| Physicians with staff working exclusively on prior authorization | 40% |
| Physicians reporting prior authorization led to a patient hospitalization | Approximately 19% to 23% |
| Physicians reporting prior authorization caused a life-threatening event or required intervention | Approximately 13% to 18% |
| Physicians reporting prior authorization led to patient disability, permanent damage, or death | Approximately 7% to 8% |
Revenue and Practice Cost Impact
Prior authorization carries both direct and indirect financial costs. The table below breaks down current estimates across administrative spending, claim rework, and patient impact.
| Cost Category | Estimated Range or Figure | Basis |
|---|---|---|
| Annual health plan interaction cost per physician | Approximately $68,000 | ReferralMD analysis of AMA data |
| Additional annual prior authorization administrative cost per physician | Approximately $1,800 | JAMA Internal Medicine estimate |
| Drug prior authorization system costs in the U.S. | Approximately $93.3 billion annually | Health Affairs study |
| Total U.S. healthcare administrative spending connected to prior authorization | Approximately $35 billion | NIH/PMC-cited research |
| Cost per prior authorization transaction for physician practices | Approximately $6 | AMA data |
| Cost to rework a denied claim | $25 to $118 per claim | HFMA and industry benchmarks |
| Administrative cost per denied claim | Approximately $57.23 | Industry benchmark data |
| Share of private payer claims initially denied | Approximately 15% | AHA analysis |
| Estimated total private payer denial burden | Approximately $20 billion | AHA |
| Estimated patient out-of-pocket increase per prior authorization disruption | Approximately $120 per patient | Peer-reviewed study, 2018 to 2021 |
- For a four-physician practice, the estimated $68,000 annual health plan interaction cost per physician may represent roughly $272,000 in administrative drag. Not all of this is prior authorization alone, but prior authorization is a major part of health plan interaction work.
- Claim rework also adds cost. If a practice receives 500 denied claims in a year and spends an average of $57.23 in administrative cost per denied claim, the rework burden alone exceeds $28,000. This figure does not include delayed cash flow, reduced provider productivity, or lost revenue from requests that are never appealed.
Implications for Practice Leaders
Prior authorization should be evaluated as both a financial risk and an operational risk. Practices that only track the number of requests submitted may underestimate the true cost of the process.
A more complete evaluation should include:
- Number of prior authorization requests submitted per physician per week
- Percentage of denied requests appealed
- Provider time spent on peer-to-peer reviews and payer communication
- Average days from request to approval or denial
- Appeal overturn rate by payer
- Number of canceled or rescheduled visits linked to authorization delays
- First-submission denial rate by payer and service type
- Staff hours spent on documentation, submission, follow-up, and rework
- Revenue delayed or lost because of denied or abandoned requests
Practices should also assess which parts of the prior authorization workflow truly require clinical judgment and which can be handled by trained administrative support. Documentation preparation, payer follow-up, status checks, portal entry, and denial tracking often do not require a licensed clinician, but they do require attention to detail, payer familiarity, and consistent ownership.
About This Report
This report was created for DocVA to help healthcare practices understand the operational and financial impact of prior authorization delays. To learn more about DocVA’s dedicated virtual assistant model, book a demo.
Sources
- 2024 AMA Prior Authorization Physician Survey
- Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024
- Exhausted by Prior Auth, Many Patients Abandon Care: AMA Survey
- Inside the Prior Authorization Crisis: Adding Costs to Practices and Delaying Care for Patients
- Perceptions of Prior Authorization Burden and Solutions
- High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care
- Payer Denial Tactics: How to Confront a $20 Billion Problem
