The Prior Authorization Workload New Federal Rules Haven't Cut

At an independent specialty practice, prior authorization rarely looks like one big task. It looks like a medical assistant checking whether a payer requires approval for an MRI, a front-desk coordinator logging into a third insurer portal before lunch, a nurse pulling chart notes to answer a request for more documentation, and someone on hold to ask whether a request submitted last week has been reviewed. None of it is billable, and almost all of it has to happen before the patient can be treated or the claim can be paid.

The scale is easy to underestimate because it is spread across so many people. In the AMA's 2025 prior authorization physician survey, fielded in December 2025 among 1,000 practicing physicians, practices reported completing an average of 40 prior authorizations per physician each week, with physicians and staff spending 13 hours a week on them. At those averages, a four-physician group is handling around 160 requests and more than 50 hours of work a week. Forty percent of physicians said they have staff who work on prior authorization and nothing else, which for a small practice means a full salary spent on a process that produces no revenue on its own.

The rules differ by payer, plan and code

Prior authorization persists as a manual job because there is no single set of rules to follow. Each insurer decides which drugs and services need approval, and the answer can differ between a payer's Medicare Advantage, Medicaid and commercial products, and change during the year. In the same AMA survey, 63 percent of physicians said it is difficult to tell whether a prescription requires prior authorization, and 62 percent said the same for medical services. Staff therefore spend time finding out whether a request is needed before they spend time making one.

The burden is not even across payers, which is part of why it resists a single fix. A practice's mix of insurers largely determines how much of the work lands on its staff, and large national plans that cover a big share of a practice's patients tend to set the tone for the whole week.

Denials add a second layer of work. Nearly a third of physicians in the AMA survey said requests are often or always denied, but only about one in five said they always appeal. Among those who don't, 52 percent cited insufficient staff or time. In other words, some care that might be approved on appeal goes unpursued simply because the practice cannot afford the hours to pursue it.

Portals, EHR tools and dedicated staff each cover part of the job

Practices have tried most of the obvious remedies, and each helps with one piece. Payer portals replaced some fax and phone work, but every insurer has its own, with its own login, forms and documentation requirements. An MGMA Stat poll from March found that 61 percent of practices had staff accessing seven or more payer portals each week. Multi-payer clearinghouse tools reduce the number of logins, but they do not reach every payer or every service, so calls to insurers remain part of the routine.

Electronic prior authorization inside the EHR is the fix most often promised, and it remains thin in practice. Only 24 percent of physicians in the AMA survey said their EHR offers electronic prior authorization for prescription medications, 27 percent said the drug requirement information shown in their EHR or e-prescribing system is rarely or never accurate, and the phone remains the most common way practices complete requests for medical services. Outsourcing to a prior authorization vendor or a remote specialist moves the labor off the payroll but not out of the workflow, since someone in the practice still has to assemble clinical notes, answer follow-up questions and tell the patient what is happening.

Hiring a dedicated coordinator is the most reliable answer, and it is the one small practices can least absorb. The coordinator becomes the only person who knows each payer's quirks, so a resignation or a week of sick leave shows up quickly as delayed procedures and unhappy patients.

Deadlines arrived in January, but the waiting moved elsewhere

The regulatory picture did change this year. Under the CMS Interoperability and Prior Authorization final rule, Medicare Advantage plans, Medicaid and CHIP programs and plans, and insurers on the federal exchanges must, starting in 2026, decide urgent requests within 72 hours and standard requests within seven calendar days, and give a specific reason for any denial. They also had to begin publicly posting prior authorization metrics by March 31, 2026. Separately, more than 60 insurers made a voluntary pledge in June 2025 to narrow and standardize their programs, and data from the insurers' trade groups, reported by AJMC in April, showed an 11 percent reduction in prior authorization requirements across participating markets, or about 6.5 million fewer requests.

Practices have not felt much of that yet. When MGMA polled medical group leaders in September, far more said turnaround times had become slower than said they had become faster. Respondents pointed to status checks, peer-to-peer reviews and heavier documentation demands, steps that sit around the regulated decision window rather than inside it.

The bigger change is still ahead. The same CMS rule requires the covered payers to offer a standard Prior Authorization API beginning January 1, 2027, and the insurers' pledge targets standardized electronic submission and real-time answers for a majority of requests on a similar timeline. For the first time, there will be a structured way for software to ask a payer whether a service needs approval and what documentation it wants, submit the request, and receive an approval, a denial with its reason, or a request for more information. Employer-sponsored commercial plans are not on the rule's list of covered payers, so practices will be working in a mixed environment for years, with some payers reachable through an API and others still through portals and phones.

Doing the assembly work before anyone logs in

Much of what consumes staff time is not judgment but assembly: matching an order against the right payer's rules, pulling the chart notes and test results a request requires, filling the same fields into different portals, and checking status until an answer comes back. Custom-built AI automation is well suited to that layer. It can read the practice's own orders and payer mix, flag which requests need approval, draft the submission with the supporting documentation attached, track every open request in one place and surface denials with their stated reasons while there is still time to appeal. As payer APIs come online in 2027, the same system can switch those payers from portal work to direct submission, while staff keep the decisions that need clinical knowledge.