Burden of Prior Authorization Requirements on Urology Practice and Patients

To determine the final outcomes of various types of prior authorizations (PAs), and to quantify the administrative and financial burden of PAs on urology practice. PAs are often required before imaging, procedures or medications can be ordered. However, they can delay timely delivery of patient care and place a significant administrative burden on practices. The impact of PAs has been poorly studied, and no studies on PAs burden on urology practice are available.

Imaging and medications requiring PAs from an outpatient urology clinic from November 2020 to February 2021 were reviewed (n = 267). Authorization outcomes were tracked to resolution. We calculated the time spent on PAs, and the estimated overall financial burden on the practice.

Of the PAs required, 60.6% were for imaging and 39.4% were for medications. Initial decision for PAs took a median of 2 days [IQR: 0-6, Range: 0-36], whereas decisions after an appeal (n = 51) took a median of 10 days [IQR: 5-23, range 0-125 days]. Private insurance compared to Medicare or Medicaid, has an earlier time to decision (P =<.001). Initial approval rates were 67.5%, and final approval rates after appeals were 88.2%. Of orders originally denied, a majority (77.3%) were appealed, 13.6% required alternative orders, and 7.6% paid out of pocket. The total cost to the practice was $2206.06, with a $15.11 mean cost of each PA.

PAs for imaging studies and medications pose a significant administrative and financial burden to urology patients and practice.