Prior authorization is a payer’s requirement that you get approval before you provide certain services, procedures, imaging or meds. This is essentially a gate that you’ve got to clear so the claim doesn’t come back denied for “no authorization on file” (even when the care made perfect clinical sense). If you’ve ever had a claim that looked clean but still got denied, prior auth is usually what’s caused it.

Why do insurers require prior authorization?

Payers use prior authorization to ensure the care you provide is in line with their policies. They’ll say it reduces waste and supports patient safety. In reality, though, it also shifts work onto your practice, because you’re the one tracking criteria and following up when someone at the plan asks for “one more note.” This is in spite of the fact that the AMA’s physician survey found that prior authorization delays access to necessary care for the vast majority of physicians who deal with it. 

What’s the difference between prior authorization and precertification?

Most practices use these terms interchangeably, and plenty of payers do too. When a payer draws a line, “precertification” often refers to confirming medical necessity under plan rules, while “prior authorization” gets used as the broader bucket that includes precert, step therapy requirements, and plan-specific approvals. From a billing perspective, however, if the payer requires an auth number and you don’t have it, you’ve got a denial risk.

What services commonly need prior authorization?

It depends on the plan, but you’ll see prior auth pop up a lot with:

– Advanced imaging

– Certain injections

– Durable medical equipment

– Higher-cost drugs

– Some outpatient procedures

Medicare Advantage plans, for instance, are especially known for heavy prior authorization use, and that matters if you have a growing MA population in your panel.

What happens if you skip prior authorization?

In the best-case scenario, you catch it early and reschedule the service. In the worst-case scenario, you render the service (and bill it correctly), but you’ll still get denied because the payer says you didn’t meet the administrative requirement. Unfortunately, that denial usually turns into appeal work and delayed cash. It can also create awkward patient conversations when the patient gets stuck in the middle.

How big of a burden is prior authorization for practices?

It’s not a small annoyance. The AMA reports practices just like yours complete a high weekly volume of prior authorizations per physician, and it’s your physicians who have to deal with the real patient harm that comes from those subsequent delays.  

MGMA has also reported that practices frequently end up hiring or reassigning staff just to keep up with prior auth workload. For a small practice, though, it just ends up feeling like you’re paying another salary just to get permission to deliver care you already know is needed. 

What does prior authorization mean for patient experience?

They will feel it as delays and phone calls. “Your insurance hasn’t approved it yet.” These delays are quite widespread. Even when an authorization denial gets overturned on appeal, the patient still lived through the delay. A large share of denied prior authorization requests that get appealed are overturned, which raises a few questions about how many initial denials should have been approvals. 

What rules or reforms should practice owners watch?

Fortunately, there’s real movement here, since CMS finalized an Interoperability and Prior Authorization rule that pushes impacted payers toward faster decisions and API-based electronic prior authorization requirements on a clear timeline. Some of those provisions start taking effect in 2026, but the key API requirements we mentioned are largely pushed to 2027.  

You’re also seeing payer-side promises to reduce prior auth requirements, especially in Medicare Advantage, though you should still treat “pledges” as something more directional rather than guaranteed relief.

How can PMN help?

Prior authorization is a key part of your revenue cycle performance, so if you want fewer avoidable denials and steadier collections, you need your documentation and claim submission to be as tight as possible.

PMN has been helping small practices build that coordination into the day-to-day workflow for over 20 years – we provide full-service billing and revenue cycle support. With a 99.98% first-time claim acceptance rate, you can be sure your practice won’t be stuck with cash flow issues.

Need support with your medical billing and coding? Get in touch by calling (949) 215-5055 or visiting our office in Laguna Hills, Orange County, California!