When a surgeon tells a patient, “You need surgery,” the patient understandably hears that the next step is scheduling it. Inside the practice, however, an entirely different process is just beginning.
The clinical decision must be converted into documentation. The documentation must be translated into the language of a payer’s policy. The request must reach the organization that actually controls the decision. Only then does the formal review begin.
Prior authorization is often discussed as though it creates a single block of waiting time. Operationally, it is more useful to think of it as three separate clocks: the time required to complete the clinical record, the time from a completed record to a clean submission, and the time from submission to a payer’s decision. Only the last of those belongs entirely to the payer.
That distinction does not make prior authorization any more defensible. It does, however, show practices where they can shorten a patient’s wait while the larger policy fight continues.
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The invisible interval
I perform spine surgery. For many of my patients, the period between deciding on an operation and receiving authorization is the longest nonclinical delay in their care. For years, I saw only fragments of that interval: a case marked pending, a request for additional records, or a peer-to-peer review appearing on my schedule.
When I began looking at the process from end to end, I found that many delays occurred before a reviewer had considered the clinical merits of the case. A note remains unfinished for two days. A case waits behind others in a work queue. A request goes to the insurer when the decision has actually been delegated to a utilization-management company. A policy requires six weeks of conservative treatment documented with dates and modalities, but the chart summarizes the treatment in a narrative paragraph. Someone must then reconstruct the history before the case can move forward.
To the patient, all of this looks like one delay. To the practice, each is a different failure point requiring a different solution.
If we measure only the total number of days, we cannot tell whether the answer is better documentation, clearer ownership, faster submission, or more forceful payer follow-up. A single number describes the patient’s experience, but it does not diagnose the problem.
Medicine tells a story; payers look for fields
The most challenging part of prior authorization is the work that looks clerical but is not. Clinical notes are written to tell a patient’s story: what is wrong, what has been tried, what the examination and imaging show, and why a particular treatment is appropriate. Medical policies often evaluate that story as a series of discrete elements: duration, dates, modalities, imaging findings, functional limitations, and documented response to treatment. A note can therefore be clinically persuasive and still be operationally incomplete.
This is where practices often struggle. If authorization is treated as simple data entry, preventable denials follow. If every policy question is sent to the surgeon, physicians spend time searching for requirements that a well-trained coordinator could identify more efficiently.
The most effective arrangement I have seen assigns the work to someone who understands both the policy and the chart. That person is not making the clinical decision. The person is ensuring that the clinical reasoning already present in the record survives its translation into the payer’s framework. That is a distinct skill, and practices should recognize it as such.
Build a reliable handoff
The goal should not be to make every note longer. It should be to make the relevant evidence easier to find.
For commonly authorized services, practices can identify the few documentation elements that repeatedly determine whether a request proceeds cleanly. Capturing those elements during the visit is more accurate and far less burdensome than reconstructing them weeks later.
Every pending case should also have three things attached to it: an owner, a next action, and a date. “Pending” is not a plan. “Waiting for a decision; Maria will check the portal Thursday” is.
Within appropriate clinical-priority categories, grouping cases by payer can also help. Requirements differ across plans, and staff members who work similar cases together become familiar with recurring criteria, submission routes, and escalation paths.
Peer-to-peer reviews deserve protected time on the schedule. They are clinical conversations about real patients, not incidental administrative calls to be wedged between visits.
Most importantly, practices should measure the intervals separately. Useful measures include:
- Time from the clinical decision to completion of the note
- Time from note completion to a clean submission
- Requests returned for missing or misdirected information
- Initial denial rates
- Appeal rates and the percentage of denials overturned
These numbers answer different questions. A high rate of requests for additional information suggests a documentation or submission problem. A high denial rate may indicate a mismatch between the treatment plan and the payer’s criteria. A high overturn rate on appeal raises a different concern: The information may have been sufficient, but the initial decision was not.
A denial is an outcome, and a data point
Practices often count denials without classifying them. That sacrifices valuable information.
A routing rejection, a denial for missing documentation, and a disagreement over medical necessity are not the same event. Pooling them into one denial rate conceals whether the remedy is operational, documentary, or clinical.
Appeals also deserve closer attention. In a 2026 review focused specifically on Medicare Advantage requests for skilled-nursing-facility admission, the U.S. Department of Health and Human Services Office of Inspector General found that only 18 percent of denials were appealed. Yet when those denials were appealed, 95 percent were overturned in favor of the enrollee.
Those findings should not be generalized to every service or specialty. They do illustrate an important asymmetry: An overturned denial becomes visible evidence that the original decision may have been flawed; an unappealed denial simply becomes care that did not occur. Appeal rates therefore tell us something about access to the appeals process, not merely about the underlying merit of denied cases.
Know when the payer’s clock starts
Since January 1, 2026, Medicare Advantage organizations and Medicaid and Children’s Health Insurance Program (CHIP) programs generally must decide standard prior authorization requests for nondrug items and services within 7 calendar days and expedited requests within 72 hours, subject to program-specific rules and permitted extensions. One detail is especially useful: The Centers for Medicare & Medicaid Services (CMS) states that the clock begins when the payer receives the prior authorization request. Merely checking whether authorization is required does not start it. Conversely, if the payer later requests additional documentation that was not disclosed when the request was submitted, that request does not automatically stop or restart the clock.
Qualified health plans on the federally facilitated exchanges are covered by other portions of the CMS rule but not by these new decision timeframes. Most other commercial and employer-sponsored plans fall outside this particular rule, although other federal or state requirements may apply.
Covered payers must also publish annual statistics that include approval and denial rates, appeal outcomes, and average and median decision times. These reports are aggregated, so they may not reveal how a specific procedure is handled. Still, they create a useful external benchmark. A practice can begin asking not only, “Why is this case late?” but also, “Is this payer’s performance consistent with its publicly reported results?”
Improve what we can without accepting what we should not
None of these operational improvements makes the current prior authorization system acceptable. According to the 2025 American Medical Association survey, practices complete an average of 40 prior authorizations per physician each week, consuming approximately 13 hours of physician and staff time. Ninety-five percent of physicians reported that prior authorization delayed access to necessary care at least sometimes, and 26 percent reported that it had led to a serious adverse event for a patient in their care. Those are physician-reported findings, but their scale is difficult to dismiss.
Practices should continue challenging unnecessary requirements, inappropriate denials, and policies that place administrative judgment between a patient and medically appropriate care. At the same time, we should be candid about the delays occurring inside our own workflows.
That is not about assigning blame. It is about refusing to make patients wait for systemic reform before improving the portion of the process already within our reach.
Comron Saifi is an orthopedic spine surgeon.
