Abstract
Prior authorization sits at the intersection of cost control, clinical decision-making, and patient access. It is also one of the most visible points where healthcare operations feel slower than they should. In Medicare Advantage alone, prior authorization touches nearly every enrollee, with 99% required to obtain approval for at least some services. The responsibility lands heavily on care teams, with physicians handling an average of 43 requests per week and spending about 12 hours completing them.
Patients experience that friction directly. Delayed access affects 94% of patients requesting prior authorization, resulting in 78% abandoning the treatment completely.
These are not edge cases. They describe what happens when evidence, policy criteria, and communication move through fragmented systems.
Regulatory expectations under the CMS-0057-F Final Rule raise the pressure further, with expedited requests expected to be handled within 72 hours and standard requests within seven calendar days. Denial communication is also expected to become more explicit through electronic means. Public reporting adds a second layer of accountability, with initial scorecard metrics due by March 31, 2026.
