Prior authorization (PA) in internal medicine isn’t just administrative red tape. It’s a significant roadblock to timely care, a frequent cause of claim denials, and a key driver of staff frustration.
Internal medicine practices handle a wide range of cases, from managing chronic diseases to coordinating complex diagnostics. This breadth makes them particularly susceptible to PA delays, denials, and inefficiencies.
In this blog, we’ll break down the most pressing prior authorization challenges in internal medicine and share actionable, data-backed strategies to streamline the process.
📌 Struggling with PA bottlenecks? Explore how our internal medicine medical billing services can help reduce denials, speed up approvals, and keep your revenue cycle running smoothly.
📢 Tired of Prior Authorization Delays Costing You Time and Revenue?
At Medibill RCM LLC, we help internal medicine practices streamline their prior authorization processes to reduce claim denials, expedite treatment approvals, and protect staff productivity.
We help you:
✔ Automate payer-specific prior authorization workflows
✔ Submit clean, complete documentation that meets medical necessity criteria
✔ Resolve denials faster with real-time tracking and expert appeals
✔ Eliminate administrative bottlenecks with EHR-integrated solutions
📍 Trusted by internal medicine providers who can’t afford care delays or are denied revenue
📅 Book a Prior Authorization Workflow Audit
Identify where your process is wasting time and money, and fix it quickly with our internal medicine medical billing services.
👉 Schedule Your Consultation Now
Table of Contents
What is Prior Authorization in Internal Medicine?
Prior authorization (PA) is a health insurance requirement in which the insurer reviews whether a treatment, test, or referral is medically necessary before covering it. While the goal is to control costs and prevent unnecessary care, the process often creates frustrating delays.
In internal medicine, PA commonly applies to:
- High-cost medications (like GLP-1 agonists for diabetes or weight loss)
- Advanced imaging (such as MRIs or CT scans)
- Referrals to specialists (e.g., cardiologists or rheumatologists)
Though PA is meant to ensure appropriate care, it can slow down treatment, especially for chronic conditions where timing matters. Many doctors argue that excessive PA requirements prioritize paperwork over patient health.
Why is Prior Authorization a Bigger Problem in Internal Medicine?
Internal medicine doctors face more prior authorization (PA) headaches than many other specialties, and for a good reason.
Their patients often have complex, chronic conditions requiring multiple medications, tests, and specialist coordination. That means more red tape.
Internists must navigate complex care workflows and insurer rules, as outlined in our Internal Medicine Billing Guide.
Why Internists Face More PA Hassles:
1. Polypharmacy Challenges
- Managing patients on 5+ medications? Common in chronic diseases (e.g., diabetes, heart failure).
- Every high-cost or specialty drug (like GLP-1 agonists or biologics) risks a PA delay.
2. Diagnostic Workups Spanning Multiple Systems
- Is it a heart issue, an autoimmune disease, or something else? Sorting it out often requires MRIs, CT scans, or lab tests, each potentially requiring a physician’s assistance.
3. Long-Term Care with Specialty Overlap
- A patient may require the services of a cardiologist and a nephrologist, as well as ongoing medical adjustments, with each step necessitating another review by an insurer.
The Real Bottleneck? Many insurers still rely on faxes, phone calls, and vague guidelines.
The result? Delays that frustrate doctors and leave patients waiting.
What Are the Main Prior Authorization Challenges in Internal Medicine?
1. Administrative Burden Drains Practice Resources
- Time wasted: Each PA request takes 15–30 minutes (or longer for appeals or peer-to-peer reviews).
- Lost productivity: Practices spend over 13 hours weekly on PA submissions instead of patient care (According to AMA)
- Outdated processes: Staff juggle manual faxes, lengthy hold times with insurers, and clunky portals.
Real-world impact: An AMA survey of 1,000 physicians in late 2024 (PDF) found that:
“89% of physicians report that PA somewhat or significantly increases physician burnout.”
2. Inconsistent & Unpredictable Payer Rules
| Payer | Turnaround Time | Submission Method | Denial Risk |
|---|---|---|---|
| UnitedHealthcare | 3–5 business days | Fax or portal | High |
| Aetna | 24–72 hours | Availity portal | Medium |
| Medicare Advantage | 5–7 days | Manual/integrated | High |
- No standardization: Policies vary widely, leading to errors and resubmissions.
- Frequent changes: Insurers update requirements without warning, disrupting workflows.
Note: Data reflects common industry trends; verify with payer-specific guidelines (e.g., UnitedHealthcare Provider Portal, Aetna Availity, CMS.gov). Policies frequently change; always confirm the current requirements.
3. High Denial Rates for “Medical Necessity”
Nearly 1 in 3 (31%) physicians said that prior authorizations (PAs) are often or always denied (AMA Survey). Industry data shows 33% of PA requests are initially rejected, frequently due to:
- Missing insurer-mandated phrases (e.g., “failed conservative therapy”).
- Generic EHR notes that don’t match payer-specific checkboxes.
- Delayed diagnostics (e.g., denied MRI for radiculopathy despite clinical guidelines).
Poor documentation is a leading cause of internal medicine insurance denials. Review common internal medicine billing errors to avoid those that contribute to denials and ensure accurate billing practices.
4. Delays in Patient Treatment
Chronic disease setbacks: Missed therapies for hypertension, diabetes, COPD, or autoimmune diseases worsen outcomes.
Increased acute care: 34% Physician said prior authorization has led to a serious adverse event for a patient in their care (AMA’s Annual Prior Authorization Physician Survey), including:
- Preventable ED visits or hospital readmissions.
- Disease progression due to postponed interventions.
Prior authorization delays often result in denied claims or abandoned care, which can drive up accounts receivable (AR). Discover how to minimize accounts receivable (AR) and prevent internal medicine billing denials.
5. Excessive PAs for Routine Care
Even low-risk, evidence-based treatments (e.g., PPIs, physical therapy) face PA hurdles, leading to:
- Patient non-compliance (due to access delays).
- Treatment abandonment (if approvals take weeks).
- Provider frustration (“Why is this even required?”).
How Can Internal Medicine Practices Overcome Prior Authorization Issues?
1. Integrate Technology to Automate and Track PA
| Tool Type | Key Benefits | Example Vendors |
|---|---|---|
| EHR-integrated PA | Auto-submits, tracks approvals | Epic, Cerner, athenahealth |
| Standalone PA portals | Cross-payer management | CoverMyMeds, Availity, Par8o |
| Tracking systems | Alerts for deadlines/appeals | MDToolbox, PAHub |
Results: A AHIP and RTI report found electronic prior authorization reduces median decision time by 69%, making the process nearly three times faster than manual methods and lowering staff burden.
Choosing the best medical billing software for internal medicine can help automate Prior Authorization (PA) tracking and submission.
2. Improve Documentation to Reduce Medical Necessity Denials
Use structured templates with the following:
- Failed prior therapies (e.g., “Patient tried metformin without adequate HbA1c control”).
- Supporting diagnostics (e.g., “MRI needed due to persistent radiculopathy”).
- Payer keywords (e.g., “medically necessary,” “no safer alternative”).
Note: Reference NCD/LCD guidelines (e.g., CMS criteria) to strengthen appeals.
Clarifying the roles of billing and rendering providers can also reduce documentation-related rejections. Read about the differences between rendering and billing providers.
3. Assign a Prior Authorization Specialist
- Role: Manages submissions, appeals, and payer portals.
- Impact: Practices report 25% faster approvals vs. untrained staff.
- Options: Hire in-house or outsource to billing/RCM firms.
4. Escalate Urgent Cases via Peer-to-Peer (P2P)
For denials, demand real-time peer-to-peer reviews with insurer medical directors.
Leverage:
- Clinical guidelines (e.g., ADA standards for GLP-1 agonists).
- ACR Appropriateness Criteria for Imaging Disputes.
Document all interactions for appeals.
Many practices choose to outsource PA management. Benefits and challenges of medical billing outsourcing for workflows.
5. Push for Systemic Reform & Gold Carding
- Support state-level gold card laws that waive PAs for high-performing physicians (e.g., thresholds vary by state/payer).
Efficient Prior Authorization (PA) handling is a crucial component of optimized internal medicine revenue cycle management.
- Texas, Georgia, and Louisiana have already implemented such rules.
- Negotiate with payers using internal audit data (e.g., “Our approval rate is 90%; reduce our PA burden”).
Ensure eligibility is verified before submitting the PA to reduce friction. Read our guide on insurance eligibility verification for internal medicine.
Prior Authorization KPIs to Monitor
| KPI | Target | Why It Matters |
|---|---|---|
| PA Approval Rate | 85% or higher | Measures documentation quality and payer alignment. Low rates indicate missing clinical justification or insurer mismatches. |
| Average Turnaround | Under 3 days | Predicts care delays. Prolonged approvals worsen outcomes for time-sensitive conditions (e.g., autoimmune flares, uncontrolled diabetes). |
| Appeal Success Rate | 60% or higher | Reflects effectiveness of denial appeals. Higher rates indicate strong clinical advocacy and payer negotiation. |
| % of Abandoned Care | Below 10% | Tracks patient dropouts due to PA delays. High abandonment correlates with preventable complications and revenue loss. |
These prior authorization metrics should align with broader internal medicine billing KPIs to benchmark performance.
Prior Authorization Case Studies in Internal Medicine
Case 1: GLP-1 Agonist for Diabetes
The Scenario:
A 58-year-old patient with type 2 diabetes (HbA1c 8.9%) needs semaglutide after failing other therapies.
What We Did Right:
Created a bulletproof documentation trail:
- Dated records showing 9 months on max-dose metformin + glipizide
- Lab reports demonstrating persistent hyperglycemia
- ADA guideline citations for cardiovascular benefit
Key Takeaway:
Even perfect documentation doesn’t guarantee smooth approval – but it does improve your odds significantly.
Case 2: MRI for Chronic Back Pain
The Scenario:
A construction worker with 3 months of radicular pain worsening despite PT (Physical Therapy).
What We Did Right:
Built a narrative insurers couldn’t refuse:
- PT notes show no functional improvement
- Exam documenting objective neurologic findings
- Safety justification (patient couldn’t safely work)
The Hidden Challenges:
- First submission rejected for “insufficient PT duration”
- Different insurers required 4-8 weeks PT (no standard)
- Took 14 calendar days total (patient lost wages)
Key Insight:
Knowing each insurer’s secret handshake matters more than clinical need alone.
Why These Cases Matter
The Good News:
- Systematic approaches work better than reactive ones
- 80% of appeals succeed with proper documentation (Counterforce Health)
The Hard Truths:
- 13 staff hours/week spent on PAs (Survey AMA)
- 1 in 5 patients delay care due to PA frustrations
For Clinicians
- Create insurer-specific cheat sheets, as UHC and Aetna requirements differ.
- Document like you’re already preparing an appeal.
- Train Medical Assistants to screen for insurance-specific hurdles upfront.
Note: These case studies illustrate common prior authorization challenges and strategies, but outcomes vary by insurer and case specifics. While not a guarantee of approval, these insights can help streamline the process.
Frequently Asked Questions (FAQs)
What is prior authorization in internal medicine?
Prior authorization (PA) is a health insurance requirement in which the payer evaluates whether a test, medication, or treatment is medically necessary before approving coverage. It often applies to chronic care prescriptions, imaging, and specialist referrals in internal medicine.
Why is prior authorization more challenging for internal medicine doctors?
Internal medicine physicians manage complex, chronic conditions involving multiple medications, diagnostics, and referrals. This increases the frequency and complexity of PA requests compared to other specialties.
How much time do internal medicine practices spend on prior authorizations?
Practices spend over 13 hours per week managing PAs. Each request may take 15–30 minutes, and denials or peer-to-peer reviews add to that burden.
What causes high denial rates for prior authorization in internal medicine?
Denials are often due to:
- Missing documentation of failed treatments
- Lack of specific phrases like “medically necessary.”
- Generic or incomplete EHR notes that don’t meet payer standards
How does prior authorization impact patient care?
PA delays can:
- Interrupt chronic disease treatment (e.g., for diabetes, COPD)
- Cause patients to abandon care
- Lead to emergency department visits or serious adverse events
What tools help internal medicine practices streamline the prior authorization process?
Top solutions include:
- EHR-integrated PA systems (e.g., Epic, Cerner)
- Standalone portals (e.g., CoverMyMeds, Availity)
- Notification software (e.g., MDToolbox) to track deadlines
How can practices reduce prior authorization denials?
- Use structured documentation templates
- Include failed treatment history and test results
- Add payer-specific language, such as “standard of care.”
- Reference CMS NCD/LCD policies when applicable
What is a prior authorization specialist, and why should you have one?
A prior authorization specialist manages submissions, denials, and appeals. Practices that assign this role report 25% faster approval times and fewer disruptions.
What is a peer-to-peer review in prior authorization?
When a PA is denied, providers can request a peer-to-peer (P2P) review with a payer’s medical director to justify medical necessity directly. This can reverse denials faster than appeals alone.
What are gold carding laws for prior authorization?
Gold carding exempts physicians with high PA approval rates from future PAs. States like Texas, Georgia, and Louisiana have implemented these rules to reduce administrative burdens.
What key performance indicators (KPIs) should be tracked to evaluate PA efficiency?
Track the following:
- PA approval rate (>85%)
- Turnaround time (<3 days)
- Appeal success rate (>60%)
- Abandonment rate (<10%)
Prior Authorization Is a Manageable Pain Point
While prior authorization isn't going away, its burden can be reduced through systemization. Internal medicine practices that leverage:
- EHR-integrated PA tools (e.g., automated form-filling, real-time eligibility checks),
- Structured documentation (payer-tailored templates with key phrases like "failed first-line therapy"),
- Dedicated PA staff or training (e.g., monthly payer policy updates)
It can significantly ease the administrative load and improve patient care outcomes.
The High Cost of Prior Authorization: A $35 Billion Burden on Healthcare
The U.S. spends approximately $35 billion annually on administrative costs related to prior authorization, with handling costs of around $11,000 per clinician per year.
Physician practices complete about 45 prior authorizations per physician per week, spending nearly two full business days weekly on these tasks, highlighting the substantial time and financial burden prior authorization imposes on practices. Systematized approaches are crucial for effectively mitigating these challenges.
