Rethinking Prior Authorization: Bridging Clinical Needs and Administrative Burdens

Prior authorization (PA) is a widely used insurance mechanism intended to ensure cost-effective, evidence-based care. However, in practice, it often imposes significant administrative and clinical burdens on health care providers and delays patient access to timely treatment. This article draws on firsthand experience in managing PAs for complex therapies, such as pediatric growth hormone treatments, to explore the evolution of PA, current operational challenges, and practical strategies for improvement. Key issues include limited formulary flexibility, step therapy requirements, lack of specialized peer review, and insufficiently trained staff handling PAs. To address these barriers, the article proposes workflow enhancements such as assigning clinically trained PA specialists, leveraging electronic platforms, using real-time benefit tools, and developing internal reference guides. By adopting structured, clinically informed approaches, health care practices can streamline PA processes, reduce turnaround times, and enhance patient care outcomes.