How to cut prior authorization denials.

The AMA’s 2025 survey of 1,000 physicians found practices complete 40 prior authorizations per physician per week, up from 39 in 2024, and spend 13 hours a week on them. 32% of physicians say requests are often or always denied, and 74% say denials have increased over five years. 40% have staff who do nothing else.

Many denials come down to process rather than clinical disagreement: missing information, a code that does not match the payer’s criteria, a request sent to the wrong channel, or a request that was never needed. A practice can fix each of those in its own process.

At a nine-provider gastroenterology practice we work with, first-time denials fell from 17% to 9% once an agent assembled each request and checked it against the payer’s rules before submission. The case.

Each payer has its own list of services that need authorization, its own forms, its own evidence requirements and its own channel. They change without notice. A practice that keeps one current file per payer, what needs authorization, what the packet must contain, where it goes, who to call, stops sending requests that were never needed and stops sending incomplete ones. It is the most common gap we see.

Check the file before you schedule. A request started at scheduling has days to clear. One started the morning of the procedure has hours.

The denial letter usually says what was missing. The fix is to check for it before submission: the diagnosis and procedure codes against the payer’s criteria, the clinical notes that show medical necessity, the prior treatments the payer requires first, the dates. A checklist per payer, or an agent that reads the chart and the payer’s rules and builds the packet the same way every time, does this. The checking is what moved the 17% to 9% above.

CAQH measured 24 minutes of provider time for a request by phone, fax or email and 16 by payer portal; a fully electronic request saves 14 minutes per transaction. Cost per manual request to the provider is $12.88 against $5.38 electronic. Portal and electronic requests also return decisions faster and leave a record, which matters for the appeal.

Where the payer takes only fax or phone, use it. Record each payer’s channel so staff don’t default to the slow one.

A request stuck in a queue holds up the patient’s care even if the payer never denies it. 95% of physicians told the AMA that prior authorization delays care, and 79% say it at least sometimes leads patients to abandon treatment. Follow up on a fixed schedule, by portal status check or by call, log every contact, and give one person ownership of the list. This is tedious work that an agent does well.

KFF’s analysis of 2023 Medicare Advantage data: more than 50 million requests, 3.2 million partly or fully denied, 11.7% of denials appealed, and 81.7% of those appeals fully or partly overturned. Few denials were appealed, and most of the appeals won.

The AMA survey explains the gap. Only 21% of physicians always appeal. Asked why physicians do not appeal, 59% do not expect to win based on past appeals and 52% do not have the staff time. The first belief is wrong on the Medicare Advantage numbers. The second is a staffing problem, and an agent can take it on: it drafts the appeal from the denial reason, the chart and the payer’s own criteria, for a person to sign.

Commercial payers do not publish comparable data, and your mix will differ. Track your own appeal rate and overturn rate for a quarter. If the overturn rate is anywhere near the Medicare Advantage figure, appeal every clinical denial.

• First-pass approval rate, per payer. This guide aims to raise it.
• Requests that were not needed. A payer file catches these.
• Days from order to decision, per payer and channel.
• Appeal rate and overturn rate.
• Staff hours per week on the whole process. The prior authorization cost calculator prices that from the AMA and CAQH figures and your own counts.