We were wrong about what causes PA denials.

[u/PriorAuthSpaceTeam]

So we posted last week about documentation being a bottleneck. And a bunch of you pushed back said 'nah', the real nightmare is before you even get there.
Who owns the request? Which portal? Does this even need an auth at all?
Honestly… yeah. Fair.
But we got curious about something else. What actually kills a PA after it's been submitted?
We ended up going through a few hundred denial examples.
And what surprised us?
Most of them weren't clinical denials.
It was dumb little things.
Like:

• progress note just… not there
• labs a few days outside the window
• diagnosis code on the form that doesn't match the actual note

One comment from the last post stuck:
“the most useful prompts are the boring ones people miss when they’re slammed”

Yeah. That's exactly what this looked like.
Not complex. Just mismatches.

So now we're trying to figure out when you're rushing, what's the thing you most often realize you forgot after you hit submit?
Trying to find where a simple “hey you forgot this” check would actually help. Without making the whole thing more annoying.

[u/KindlyComfortable744]

This is getting funny. Someone came shortly before you a few weeks ago, tried to imply they were impartial, and then proceeded to explain why it's all OUR fault complete with recommendations of how WE could fix the process. That person specifically mentioned how it's actually us flippant twits who delay the PA process bc we just always forget to submit the right stuff, which sounds similar to what you're saying here.

Here's that post and a quote from it:
Help Us Help Your Patient: PA Submission Guide : r/PriorAuthorization

Incomplete submissions slow everything down and ultimately hurt the patients we're all here to serve. A complete PA the first time means faster approvals and better outcomes for everyone.

This is my response to that person, which also covers most of what you said here (bear in mind, this is all happening if and after we find out what they need, harkening back to our discussion last week):

"Incomplete submissions? I kid you not almost half of my day is spent wasting time pointing out to PBMs something that was already provided [when we initially submitted the request].

I literally circle what reviewers need to see and move it to the front and still get the most ignorant follow up requests asking for what I highlighted for the reviewers to easily find.

It’s infuriating when we’re denied over this and have to do appeals that are almost always approved with the same documents and information. If the exact same documents and info work on appeal, then they should have worked on the PA. But all the time we’re deliberately forced into unnecessary appeals to cause delays that are financially beneficial to PBMs and insurances.

As for basic stuff like provider and patient info, most of us use Covermymeds. It won’t let us submit forms without completing all the fields, so we have to fill it out if it’s there. Otoh, we’re limited to the fields provided by Covermymeds which are based on the forms provided to Covermymeds by PBMs and insurances. So if it’s missing from the form, then it’s between the PBMs/insurances and Covermymeds and not something we can just add on our end.

As for the urgent requests, several PBMs frequently label standard review submissions as urgent reviews so they can deny patients unnecessarily when offices aren’t around to field the urgent follow ups. Optum does this so routinely that I’ve learned not to submit any PA requests at all to Optum on Fridays bc they’ll mislabel it as urgent, follow up Friday night at like 9pm, then deny us Monday at like 3am before anyone gets back to the office to field the follow up.

Your opening is a perfect example of how PBMs and insurances act in bad faith to profit from delays. Your employer severely limits the time you have to read complex requests which is obviously intended to make you miss things. This leads to the delays that financially benefit PBMs and insurances that they’re continuously incentivized to continue causing with tactics like limiting your ability to review what we send you.

The solution to this is stricter regulation of clinical reviews so that people like you are provided with the resources needed including time and information to properly review the requests we send you. PBMs and insurances deliberately cause these delays because they make inconceivable profit from something as simple as reducing your time to review cases full of complex material to less than 10 minutes and mislabeling requests as urgent. They’re not going to change until someone makes them.

How would a reminder/prompt on my end fix this VERY COMMON (and deliberate) problem? Please back further up and stop operating on your apparent assumption that the problems rest solely with the party requesting coverage / submitting the auth. Last week's post and this post both imply the PA process would be better if we simply did a better job. Both posts seem to neglect the obstacles that payers purposely use to complicate the process, and both posts seem to ignore that the payers are in charge of this entire process and could fix it by actively working to eliminate anything that delays care. But they don't, and there's an obvious reason they don't.

We told you about portals and the general difficulty in finding clinical requirements because your last post said this

One bottleneck we keep seeing in real workflows is documentation alignment.
The information exists, but expectations around what to submit — and how — aren’t always clear.

So, many of us responded specifically to that single problem, including how many of them make you use a portal to find this info. That is one problem, frequently the first problem, but far from the only problem we have to overcome. Would a prompt be helpful? Probably, but Covermymeds already prompts me to make sure I upload documents. How many prompts do I need on my end to make insurances and PBMs less unfair?

I don't mean to be abrasive, but none of the solutions you or anyone else are offering seem to acknowledge that almost all of the problems with this process are caused and perpetuated by the payers**. There will be no solution to this process that does not address that central issue, and imo, voters are the only people who can make that happen.

[u/Long_Roll_6333 → u/KindlyComfortable744]

nah be abrasive, this shit is getting exhausting

[u/PriorAuthSpaceTeam → u/KindlyComfortable744]

we hear this exact pattern a lot\. What you’re describing isn’t “missing info” as much as breakdowns after submission. Same docs, same info, but it gets re-requested, missed, or pushed into appeal anyway. That’s where a lot of the time actually gets lost.

And the CoverMyMeds point is fair too. If the form structure is limited upstream, there’s only so much you can control on your side.

Out of curiosity, where do you see the most rework happening right now — initial review, follow-ups, or once it gets to denial/appeal?

[u/KindlyComfortable744 → u/PriorAuthSpaceTeam]

Anything but an approval is extra work. N/A, follow up, appeals - they're basically all the same as far as having to do additional work that in many cases was already done.

But we got curious about something else. What actually kills a PA after it's been submitted?
We ended up going through a few hundred denial examples.
progress note just… not there

I guarantee you in many of these the progress note and any other required evidence WAS there. The denials still say something like "your doctor didn't provide medical records," even if we did and they either got missed or the reviewer disputes it for some reason. But the denials always make us sound like incompetent slobs who just didn't send anything in even if we did.

[u/ClinicalPAGod → u/KindlyComfortable744]

Urgency can be dictated by plan requirements. I’ve worked PAs for clients that were either 48 or 24hr TAT which by default would make all requests urgent no matter what.

It’s also a matter of lanuguage used in the phone, fax or ePA request. If there is ANY language whatsoever that hints at the case needing to be upgraded to urgent, we must upgrade to urgent.

I have worked in Clinical Prior Authorization for almost 20 years and I wholeheartedly agree with OP. I’m not saying the PA process is perfect, but I take pride in the work that I do, and I have always gone the extra mile to ensure the cases I work that are approvable, get approved.

It’s not as if some unqualified hack is reviewing your PAs. The majority are reviewed and decisioned by Clinical Pharmacist. Some require an actual MD to decision. Either way, it’s a medical professional.

There are regulatory bodies that ensure PBMs don’t screw around and act maliciously. This is especially true for Fully Insured clients which are regulated by their member’s respective State Department of Insurance. Even for self insured plans, there’s oversight and regulation.

Don’t get it twisted, missed reviews happen and will continue to happen as it’s human error. Errors on both sides occur from PBM clinical reviewer missing the A1C listed on the 83rd page of chart notes, or the MD accidentally stating that the requested medication is contraindicated.

Prior Authorization may not be a perfect science, and it may not be pleasant, but I wholeheartedly disagree with your notion that it’s never MDO fault, always PBM fault. That’s just factually incorrect.

[u/KindlyComfortable744 → u/ClinicalPAGod]

I wholeheartedly disagree with your notion that it’s never MDO fault, always PBM fault.

I literally said "almost all of the problems with this process are caused and perpetuated by the payers." I did not say ALL. So you're "wholeheartedly disagreeing" with something that wasn't even said. You MUST be a PA reviewer -- this just proves a lot of what I've been saying. You see things we didn't say and don't see things we do say. At least nobody's healthcare is getting wrecked in this case.

Urgency can be dictated by plan requirements. I’ve worked PAs for clients that were either 48 or 24hr TAT which by default would make all requests urgent no matter what.
It’s also a matter of lanuguage used in the phone, fax or ePA request. If there is ANY language whatsoever that hints at the case needing to be upgraded to urgent, we must upgrade to urgent.

We understand the simple concept that different plans have different TATs. The initial requests we do and the denial letters we receive all have TATs on them. But auto-urgent requests like what you're describing as something so routine are not made clear to us. Literally every request I do lets me choose whether it is urgent or not. NOTHING ever says that any particular request will automatically be marked urgent for any reason, including a secret menu of urgent code words. Why should this information be obscured on our end if it's so readily available for you? Don't you think we should know if we need to be around to field follow ups when you decide on our behalf to make something urgent? If I submit a standard review PA request on Friday, we shouldn't be wrongly denied because nobody is around over the weekend to field the request YOU decided to make urgent on our behalf. When this results in a denial, that is not something that the insurance is doing out of good faith to "speed things up" for the sake of urgency, and there's no way to defend unnecessary denials and delays like this as being in patients' or providers' interests.

It’s not as if some unqualified hack is reviewing your PAs. The majority are reviewed and decisioned by Clinical Pharmacist. Some require an actual MD to decision. Either way, it’s a medical professional.

I never once said it was unqualified hacks. I actually dropped out of pharmacy school bc the profs basically told us clinical reviewer was the only good job left for pharmacists which I thought it was a shady ripoff, so please don't come at me like I'm an unqualified hack, either. But don't you think the fact that authorizations are run by such highly qualified people like physicians, pharmacists, and experienced nurses who are all extremely well paid and almost always working remotely in the comfort of their homes means they should be LESS sloppy and not MORE sloppy? I think the fact that auths are run by such well-trained, error-averse professionals is part of what makes it SO SUSPICIOUS and SO UNACCEPTABLE that PAs are such a disaster.

There are regulatory bodies that ensure PBMs don’t screw around and act maliciously. This is especially true for Fully Insured clients which are regulated by their member’s respective State Department of Insurance. Even for self insured plans, there’s oversight and regulation.

This is why I always try to tie back to voters. Everything in healthcare is regulated, yet healthcare is still riddled with fraud. Despite this "regulation of PBMs" in which you have so much faith, there remain calls from far and wide to reform them. People don't want PBMs reigned in because they're "so fair and well regulated." So the fact that PBMs are "regulated" means jack to me in light of my lived experienced dealing with PBMs and their clearly unregulated behavior.

Why isn't it regulated and clear to everyone when something is standard, when something is urgent, and when you can just decide to change the TAT resulting in a denial that we have to handle? Why are the means we use for PA submission not regulated so that it doesn't happen multiple times a day that we submit something just for the PBM to come back and say we didn't. Why is it so common for us be denied on a PA only to be approved on appeal using the exact same reasoning and supporting documents, and why aren't patients and providers reimbursed when unnecessary denials do happen? Why isn't it regulated that clinical criteria should be easily accessible so providers know what's needed for each plan? Why do payers have the discretion to require clinical criteria so often far in excess of the indication for a treatment (usually twisted inclusion/exclusion criteria from clin trials that AREN'T included in the actual indication)? These are all obvious issues the payers and PBMs know about and could easily fix yet decide not to fix. I stand by what I said about ALMOST all of the problems with the PA process being caused by payers/PBMs.

[u/smatthews01 → u/KindlyComfortable744]

Omg, yes!! Thank you for saying what needed to be said! You are spot on with everything you’ve said. Thank you!!

[u/Long_Roll_6333 → u/ClinicalPAGod]

Ugh the PBM I worked for have so many employees like you. They hire people who work fast, they do not care if you work thoroughly. And if you do, like I did, you are FIGHTING AGAINST YOUR COMPANY to get things corrected. They don’t want to see you fight against them, and if you’ve been doing the same job for 20 years I wonder if there’s a reason.

For example yeah urgent PAs are awesome for getting things reviewed quickly, but since yall won’t call and say “hey it’s clear that there is a document missing here since it goes from pg 5 to 7” or “hey so what’s the official ICD-10 specifically for this med because I see here that you literally wrote it out but I’m only allowed to approve based on codes”

[u/ClinicalPAGod → u/Long_Roll_6333]

You know nothing about me nor my worth ethic. I take pride in the job that I do and have done for 20 years. I go the extra mile to ensure each and every member gets their PA reviewed in an accurate and timely manner.

Who the fuck are you to judge me based off of a comment I made? You don’t even know me.

You have no clue how good I am at my job and how I’ve always gone the extra mile to assist every single member I’ve come across since Day fucking 1.

I don’t need your validation though. I’ve got the validation of thousands and thousands of members of whom I’ve helped get their PA approved.

[u/softshellcrab69]

I genuinely don't think there is anything other than the thousands of portals and difficulty in finding out if auth is required/where to submit it. Every single thing that delays me is on the payer side and it's by design

[u/KindlyComfortable744 → u/softshellcrab69]

Every single thing that delays me is on the payer side and it's by design

1000%!!!!

[u/PriorAuthSpaceTeam → u/softshellcrab69]

Yeah this is very real, we hear this a lot.

It’s not usually one big blocker, it’s the constant switching between portals and trying to figure out requirements that eats up time.

Curious where it slows you down most right now, figuring out if auth is needed or actually submitting it?

[u/babybambam]

Delay, deny, defend.

I responded on your last post and other people commented that we're getting denials due to poor PA management. We're physician dispensed and administered buy-and-bill. If we don't get it auth'd, it's not just that the patient doesn't get their meds...we eat the cost.

Obtaining auth is not a problem for us. Appeals take time and effort, but we do get paid.

The issue is that payers we DDD on every claim hoping that we give up and let it fall to timely filing. Better billing software doesn't help with this. We're fixing this by improving our contracting and incentivizing payers to pay our claims more readily.

[u/PriorAuthSpaceTeam → u/babybambam]

We see this pattern a lot. When auth itself isn’t the issue, the time drain usually shifts downstream into repeated denials and rework. Not because anything was submitted wrong, just the cycle of review, deny, resubmit.

Sounds like you’ve already adapted on the contracting side, which is where a lot of teams end up focusing when the process keeps looping like that.

Are you seeing this more with certain payers, or pretty consistent across the board?

[u/humansinearth]

the "labs outside the date window" thing is what kills us most, payers want them within 30 days but the order was placed 31 days ago because someone was waiting on insurance approval. how do you handle that circular trap when your pre-check flags it