An oncologist knows exactly which medication could stop or slow a patient’s tumor from growing—but before the first dose can be administered, the insurer must sign off. That sign-off, known as prior authorization, can take days or even weeks and in that time, the disease may progress and symptoms can worsen.
Prior authorization is meant to serve an important purpose: ensure that treatments are medically necessary, evidence-based, and covered by a patient’s plan. But in practice, the process often drives a wedge between clinical decision-making and patient care.
For providers, it adds hours of administrative work. In some instances, prior authorization can lead to significant delays in patient care, ultimately negatively impacting patients’ quality of life. In instances where information is incomplete, it can lead to denied treatments. Physicians on Sermo have weighed in on the burdens of prior authorization as well as common misconceptions among their patients.
How prior authorization delays patient care
The complexities of prior authorization can delay patient care, causing more harm than good for the patient. The process often includes back-and-forth communication between providers and insurers, which can postpone and even prevent access to treatments, medications and diagnostic tests.
An OBGYN in the Sermo community described prior authorization as “one of the biggest obstacles” in daily clinical practice. “It not only takes away valuable time from direct patient care, but often delays urgent treatments with a real impact on clinical outcomes,” they explain.
The waiting period can worsen the patient’s health and add significant stress and anxiety to both the patient and the healthcare provider. In some instances, a patient may give up on treatment altogether if they experience delays or denials from their insurance. In a survey of 1,000 physicians conducted by the American Medical Association (AMA), 78% reported that prior authorization often or sometimes results in a patient abandoning a recommended course of treatment.
In a recent Sermo poll, members ranked delays in treatment as the top impact of prior authorization on their workflow (39%), beating out issues like lost time spent on paperwork (26%) and frustration among staff (12%).
The burden of prior authorization on clinical workflow
While prior authorization serves a purpose, it diverts significant time and resources to administrative paperwork, phone calls, and appeals.
An internist on Sermo states that their patients “often have delays in care for appropriate medications due to prior authorizations that are wildly inappropriate.”
Their experiences are consistent with the overall Sermo community. In a poll, 34% of physicians said the delays occur several times per week, 25% notice them daily and 24% experience the issue a few times per month.
In some instances, physicians may alter their clinical decisions because of prior authorization requisites. A 2023 study found that requirements around step therapy, which encourage the use of lower-cost drugs before moving to more expensive ones, had the biggest effect on clinical decision-making. Communication issues and perceived likelihood of successful prior authorization also had significant effects.
To help minimize the issue in the U.S., the Centers for Medicare and Medicaid Services (CMS) released the Interoperability and Prior Authorization Final Rule, which payers are required to start implementing on January 1, 2026. It includes measures intended to improve the prior authorization process, like requiring payers to respond to urgent send prior authorization requests within 72 hours and standard requests within seven days.
Patient misconceptions about prior authorization
Sermo members have weighed in on patient misconceptions surrounding prior authorization, including the following:
Physicians are responsible for the delay
In a Sermo poll, 35% of members said the biggest misconception among patients is that physicians are responsible for the delay in prior authorization.
In reality, physicians are just one step in the process. They are responsible for initiating the prior authorization process to get insurance approval for treatments and medications. However, much of the delay comes from the process’s burdens. Insurance requirements, a lack of standardized workflows and errors in patient billing information can also lead to delays.
This was also the misconception that members said they most wish patients knew the truth about in response to a separate poll question. “I think the most important thing would be for patients to understand that physicians don’t use prior authorization to stop their care; rather, it’s an administrative barrier beyond our control,” states one oncologist.
That it’s a quick and automatic process
Patients often seek convenience, ease and urgency when it comes to healthcare. 22% of polled physicians on Sermo indicated that the main misconception around prior authorization is that it’s a quick and automatic process. Prior authorization involves a multi-step manual process that includes submitting extensive information, insurer review and potential appeals.
An internist on Sermo described the process: “I have to do this myself and I mostly have to do it over the phone live, as the sites where it can be done on line are a nightmare to get signed up to or difficult to access.”
That it guarantees coverage or approval
Prior authorization does not guarantee coverage or approval. Many patients may assume so due to the lack of transparency surrounding prior authorization, confusing medical terminology, and the complexities of the process. 22% of polled physicians highlighted this as the most prevalent myth around prior authorization.
That itʼs unnecessary bureaucracy
Given the downsides, patients may assume that prior authorization is unnecessary. However, prior authorization does serve a purpose, as it ensures proposed medical services and medications are medically necessary and cost-effective. “Prior authorization can feel like a frustrating bureaucratic hurdle, but there’s a lot beneath the surface that patients often don’t see,” remarks an oncologist and Sermo member.
Patients generally understand it well
Patients may assume they understand prior authorization and what it means for them, but this is not always the case. Denial letters often lack clear reasons for the decision, making it challenging for physicians and patients to understand what steps are needed for approval. Moreover, health plan rules and clinical guidelines are sometimes vague, making it difficult to understand what is covered and what is not.
Systemic changes to improve the prior authorization process
Sermo members have called for improvements to the prior authorization process. Namely, polled members believe that elimination of prior authorization for certain evidence-based treatments (47%), better transparency around approval timelines (18%) and streamlined platforms (18%) would make the biggest impact.
Physicians have taken to Sermo to assert their desire for prior authorization reform. “Prior authorisation causes unnecessary delay in [patient] care and puts a burden on clinicians,” laments an oncologist. “There has to be a way to facilitate this.”
An internist shared their suggestion: “Prepare a committee involving pharmacists and physicians hired to deal with administrative issues to address PA so it can alleviate the burden from practicing physicians.”
Physicians are also advocating for electronic submissions to speed up processing, reduce administrative burdens and improve accuracy.
Doctorsʼ overall thoughts on prior authorization
Sermo members have highlighted healthcare policy issues within the prior authorization process that are counterproductive to patient care. “PAs create a burden on everyone and cause unnecessary delays in care,” argues one family medicine physician. “The insurance companies are the only ones who donʼt suffer negative consequences from them.”
Sermo feedback suggests that prior authorization has become a major contributor to moral injury and burnout, forcing doctors to fight for necessary care. In some instances, physicians align themselves with a system that’s broken and make decisions that go against the patient’s best interest.
A Family Medicine doctor on Sermo described the effects. “Extremely tiring and dealing with bureaucracy can be challenging, as the patient often struggles to understand that certain demands are not within the medical team’s control, but rather depend on the hospital and administrators,” they write. “This makes it extremely tiring to deal with on a daily basis, further complicating and complicating the doctor-patient relationship.”
Some Sermo members have advocated for policymakers to reduce harmful barriers to patient care. They argue that prior authorization reform has the potential to preserve physicians’ professional integrity and time for patient care. Join in to connect with physicians globally, share insights, gather evidence and add your voice to the mix.
