If prior authorization is eating your front desk's day, delaying patients or showing up as denials, outsourcing it usually pays for itself. A good prior authorization service does more than fill in payer forms: it decides which visits need an approval, builds the medical necessity case, chases the payer until there is a decision, and makes sure the authorization number actually lands on the claim.
Should you outsource prior authorization?
Outsourcing makes sense when one or more of these is true for your practice:
- Staff time is going to hold queues and portals instead of patients, scheduling and collections.
- Visits get rescheduled because an approval was not back in time.
- Claims deny for missing or expired authorization, or for more visits than were approved.
- Nobody owns renewals, so a course of therapy, imaging series or infusion plan runs past its approved dates before anyone notices.
- You added a payer or a provider and the rules for that plan live in one person's head.
It makes less sense if your specialty rarely needs approvals and the few you do need are handled cleanly today. In that case the gains are small and you should spend the effort on eligibility checks and denial follow-up instead.
What prior authorization is costing practices now
The American Medical Association's 2025 prior authorization survey of 1,000 practicing physicians, released May 13, 2026, found that physicians complete an average of 40 prior authorizations a week, and that the work takes an average of 13 hours of physician and staff time each week. Two in five physicians (40%) employ staff who work only on prior authorization. More than nine in ten (95%) say it delays access to necessary care, and nearly four in five (79%) report patients abandoning treatment because of authorization problems.
The cost also shows up on the remittance side. In KFF's analysis of 2024 federal data on HealthCare.gov plans, lack of prior authorization or referral was the stated reason for 9% of in-network claim denials where a reason was reported. Those denials are often the hardest to win back, because the approval cannot be obtained after the fact for many plans.
What a prior authorization service should actually do
Use this as a checklist when you compare vendors, or when you audit your own process:
| Step | What good looks like |
|---|---|
| Requirement check | Every scheduled visit is checked against the patient's plan and the payer's current authorization list before the appointment, not after the claim denies. |
| Clinical packet | Diagnosis, history, prior treatments and the payer's own criteria are pulled from the chart and matched point by point. |
| Submission | Sent through the payer's portal or electronic channel, with a reference number logged the same day. |
| Follow-up | Pending requests are worked on a schedule, and requests for more information are answered quickly so the clock does not reset. |
| Peer-to-peer and appeal | Denials are flagged to the provider with the payer's stated reason and the deadline, and the appeal letter is drafted for signature. |
| Tracking | Approved units, visit counts and end dates are tracked, and renewals start before the approval runs out. |
| Claim link | The authorization number and approved dates are on the claim, and services outside the approval are caught before submission. |
The last two rows are where most in-house processes break. The approval was obtained, but the visit count ran out, or the claim went out without the number.
What the 2026 CMS prior authorization rule changes
The CMS Interoperability and Prior Authorization final rule (CMS-0057-F) applies to Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the federally facilitated exchanges. CMS calls these "impacted payers". Under the rule:
- Impacted payers, other than QHP issuers on the exchanges, must send prior authorization decisions within 72 hours for expedited (urgent) requests and within seven calendar days for standard requests.
- Beginning in 2026, impacted payers must give a specific reason when they deny a prior authorization, however the request was sent.
- Payers must build a Prior Authorization API that says whether a request is approved, denied (with a reason) or needs more information, generally by January 1, 2027.
Two practical points for a practice. First, the rule does not cover every plan you bill: employer plans and other commercial coverage outside that list keep their own timelines. Second, a specific denial reason is only useful if someone reads it and acts on it before the appeal window closes. Faster decisions help most when your requests go in complete the first time.
In-house or outsourced prior authorization
| In-house | Outsourced | |
|---|---|---|
| Control | Staff sit next to providers and can ask questions directly. | Works through your EHR access and a shared queue; needs a clear handoff. |
| Coverage | Stops when the person who knows the payer rules is out. | A team covers volume spikes, vacations and turnover. |
| Payer knowledge | Limited to the payers your staff see often. | Built across many practices and plans. |
| Fit | Low volume, one or two dominant payers. | Steady volume, several payers, or renewals that keep slipping. |
Questions to ask a prior authorization company
- Do you check authorization requirements before the visit, or only submit requests we send you?
- Who prepares the clinical documentation, and how do you match it to each payer's criteria?
- How do you track approved units, visit counts and end dates, and when do renewals start?
- What happens when a request is denied: who is told, how fast, and who drafts the appeal?
- Can you show us a weekly report of pending, approved and denied requests by payer?
- Do you also bill the claim, so the authorization number is checked before submission?
How Sterling Global Solution LLC handles prior authorization
We start the authorization when the visit is scheduled, alongside eligibility and benefits verification, so problems surface days before the patient arrives. Our team builds the medical necessity documentation from your notes, submits it, follows up with the payer and tracks every approval to its end date. Because we also scrub and submit the claim, the authorization number and the approved service dates are checked before the claim leaves, which is where many authorization denials are actually created.
Prior authorizations are part of our 30-Day Free Trial, together with eligibility verification, benefits verification and denial management, so you can see the process on your own patients before you commit. For specialty detail, see how we handle authorizations in behavioral health, ABA therapy, cardiology and orthopedics.
Frequently asked questions
What does a prior authorization service do?
Is it worth outsourcing prior authorization?
How long does a payer have to decide a prior authorization in 2026?
How many prior authorizations do physicians handle each week?
Is prior authorization included in the 30-Day Free Trial?
Sources
American Medical Association, AMA survey: Prior authorization reform pledge falls short with physicians, May 13, 2026, and the 2025 AMA Prior Authorization Physician Survey: authorizations per week, hours per week, dedicated staff, care delays and abandoned treatment.
Centers for Medicare & Medicaid Services, CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet: impacted payers, decision timeframes, denial reasons and API dates.
KFF, Claims Denials and Appeals in ACA Marketplace Plans in 2024, March 24, 2026: share of in-network denials for lack of prior authorization or referral.
Payer rules change often and vary by plan. Check each payer's current authorization list before scheduling. How we verify this guidance.
Related reading
- Prior authorization is broken. Here's how to fix it. Where the process breaks inside a practice and what to change first.
- Behavioral health prior authorization in 2026. Why authorizations lapse mid-episode in mental health care.
- Denial management services. What to do with the authorization denials that still get through.
- Claim denied as not medically necessary. How to respond when the payer says the service was not needed.
- All billing and RCM services. Eligibility, benefits, coding, claims, AR and reporting in one place.
Hand us your prior authorizations
Eligibility verification (EV), benefits verification (BV), prior authorizations, and denial management at no cost for your first 30 days.
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