Ask any practice manager where the week goes and prior authorization will come up fast. It's the process where a health plan requires approval before a medication or service is covered, and for most practices it has become one of the heaviest administrative loads they carry.
The size of the problem
The American Medical Association surveys 1,000 practicing physicians on prior authorization every year. Its 2025 survey found that practices complete an average of 40 prior authorizations per physician per week, that physicians and their staff spend roughly 13 hours a week on them, and that 40% of physicians have staff who work exclusively on prior authorization.
Four in ten physicians have staff who do nothing else.
The cost isn't only time. In the same survey, more than one in four physicians (26%) reported that prior authorization had led to a serious adverse event for a patient in their care.
What's changing
In January 2024, CMS finalized the Interoperability and Prior Authorization Final Rule (CMS-0057-F). It applies to Medicare Advantage plans, Medicaid and CHIP programs, and qualified health plans on the federal exchanges. Key changes include:
- Decisions within 72 hours for urgent requests and 7 calendar days for standard requests, starting in 2026.
- A specific reason when a request is denied.
- Public reporting of prior authorization metrics by plans.
- Electronic prior authorization APIs, with a compliance date of January 2027.
Separately, in June 2025 more than 60 health insurers made a voluntary pledge to reduce the scope of prior authorization and standardize electronic requests, with commitments phased in through 2027.
What practices can do now
Faster payer timelines help, but they don't fix incomplete submissions. Missing or inaccurate information is the most common reason claims are denied, cited by half of providers in Experian Health's 2025 State of Claims survey. The practical wins are upstream:
- Make sure documentation is complete before anything is submitted.
- Track every open request and follow up before it stalls.
- Give the team one view of what's pending, approved or denied.
That checking, chasing and tracking is exactly the work Sebastian Network takes off your desk, so those hours go back to patients.
