A Missing Authorization Is Not a Claim Problem. It Is a Scheduling Problem.
By the time a claim comes back denied for no authorization, the service has already been delivered, the appeal window is ticking and the patient has been billed for something your practice agreed to cover. The only durable fix is upstream: knowing what needs authorising before the appointment is booked, and having the approval in hand before the visit. That is the work we run.
Why Prior Authorization Keeps Costing You Money
The denial arrives on a claim, so it gets treated as a billing problem. The cause is almost always upstream of billing, and it repeats every week until the front end changes.
Requirement lists change without notice
Payers add and remove services from their prior authorization lists on their own schedule, sometimes quarterly and sometimes overnight. A CPT code that never needed authorisation for a commercial plan can require it after the next policy update, and the practice only finds out when the first claim for that code comes back denied with a reference number instead of a payment.
Authorisation is checked after the visit
In most practices the check happens when the claim is scrubbed, which is days or weeks after the service was delivered. At that point the only options are a retrospective request, which many payers refuse outright, or an appeal arguing medical necessity for a decision the payer was never asked to make. Both are worse than a five minute check before the appointment was booked.
Clinical packets do not match what the payer asks for
Every payer publishes its own evidence list: conservative care tried first, specific imaging, functional scores, treatment history, failed therapies. A packet that includes everything is not the same as a packet that includes what that reviewer needs. Insufficient documentation is reported as a clinical denial when it is actually an assembly problem.
Nobody tracks the authorisation once it is approved
Approvals carry unit limits, visit caps and expiry dates. A practice with an approved authorisation for twelve visits that delivers fourteen has two unauthorised visits, and the claim for visit thirteen is denied on exactly the same basis as if no authorisation existed. Unless units and expiry are tracked at the point of scheduling, this happens silently every month.
Peer to peer is treated as a last resort
A peer to peer conversation between the treating clinician and the payer medical director overturns a meaningful share of clinical denials, and it has a short window attached. When nobody is assigned to schedule it, the window closes and the practice escalates to a written appeal that costs more, takes longer and wins less often.
Denials are appealed without reading the reason
Since the interoperability requirements took effect, denials have to state a specific reason. That is an advantage for a practice that reads it. An appeal that argues the wrong issue wastes the appeal level entirely, and payers count the levels. By the time the real issue is addressed, the practice may have exhausted its internal appeals.
From Scheduling to Approval in Five Steps
The sequence matters more than the effort. Checked in the wrong order, the same work produces denials.
Check the requirement before the appointment
Every scheduled service is verified against the payer's current requirement list and the patient's specific plan, not against last year's list and not against the practice's memory of how that payer usually behaves. Plan level detail matters, because two patients on the same payer in the same clinic can sit on plans with different requirement rules.
Assemble the clinical packet the payer asks for
We build the submission to that payer's published evidence list: the referring documentation, the conservative care history, the imaging, the functional measures and the treatment plan. Where the requirement is a specific form or portal, we use it. Where the payer accepts clinical notes, the notes go in a readable order with the relevant sections marked rather than as a chart dump.
Submit and track to a decision
Submissions go in through the payer's own channel with an acknowledgement retained as proof. Every request carries a decision deadline based on the payer's own standard, 72 hours for expedited requests and seven calendar days for standard ones under the current rules, and we chase on the date the answer is owed rather than waiting for a portal to change.
Overturn the denials worth overturning
When a request comes back denied, the stated reason drives the response. Missing documentation gets a supplement. Clinical criteria disputes get a peer to peer with the treating clinician where the payer offers one. Criteria misapplication goes to the next appeal level with the policy language quoted back at the payer.
Track units, renewals and expiry
Approvals are logged with their authorised units, visit limits and expiry dates, then reconciled against what was actually delivered. Renewals are started before the current authorisation expires rather than after the next appointment has already been booked, which is the single most common cause of a gap in behavioural health and therapy authorisations.
The Work Inside Prior Authorization Management
Six workstreams that keep authorisations ahead of the service instead of behind the claim.
Requirement verification
Payer and plan level checks at scheduling, so the practice knows before the visit what needs authorising.
Clinical packet assembly
Submissions built to each payer's published evidence list, in the order the reviewer reads them.
Submission and tracking
Every request logged with an acknowledgement and a decision deadline based on the payer's own turnaround standard.
Peer to peer coordination
Scheduling the clinical conversation inside the payer's window, with the treating clinician briefed beforehand.
Denial appeals
Appeals built around the stated denial reason, escalated through the payer's levels where the money justifies it.
Units, renewals and expiry
Approved units, visit caps and expiry dates reconciled against delivered services, with renewals started early.
What Changes When Authorisation Runs Upstream
Same payers, same services and the same clinicians. The difference is when the work happens and who is accountable for it.
| What changes | Without a process | With MedFactor |
|---|---|---|
| When the check happens | When the claim is scrubbed, days later | Before the appointment is booked |
| Requirement source | Last year's list and staff memory | The payer's current policy at plan level |
| Documentation | Everything, in chart order | What the payer's evidence list asks for |
| Decision chasing | Waiting on the portal | Chasing on the date the answer is owed |
| Denied requests | Written appeal only | Peer to peer where offered, then escalation by stated reason |
| Approved authorisations | Not tracked after approval | Units and expiry reconciled against delivered visits |
Prior Authorization Questions Answered
What practice managers and clinicians ask before moving authorisation work off the front desk.
Prior authorization is the payer's requirement to approve a service before it is delivered. It causes denials because the check usually happens after the service rather than before it. Once the visit is complete, the practice can only ask the payer retrospectively or appeal a decision the payer was never asked to make. The denial lands on the claim, so it looks like a billing failure when the decision point was weeks earlier, at scheduling.
The current CMS interoperability requirements apply to impacted payers: Medicare Advantage, Medicaid and CHIP fee for service and managed care, and qualified health plans on the federal exchanges. They do not apply to commercial group plans, which set their own turnaround expectations in the provider contract. Expedited requests from impacted payers must be decided within 72 hours and standard requests within seven calendar days.
Two things that work in your favour. Denials must now state a specific reason, which makes a well built appeal far more likely to succeed because you are arguing the actual issue rather than guessing at it. Payers are also required to expose a prior authorization API by 1 January 2027, which over time replaces portal and fax submissions with a query and response that can be logged automatically. Payers have reporting obligations in the meantime, so their own approval data becomes public as well.
We log the approved units, visit caps and expiry date for every authorisation and reconcile them against what was delivered. This matters most in behavioural health, therapy and other services authorised by units per week or total visits. A practice that delivers fourteen visits on a twelve visit authorisation has two unauthorised visits, and the second one is denied exactly as if no authorisation existed at all.
A peer to peer is a conversation between the treating clinician and the payer's medical director to discuss a denial on clinical grounds. Payers offer it on a short window, often a few business days from the denial. It overturns a meaningful share of clinical denials at a fraction of the cost of a written appeal, which is why we schedule it as soon as the denial reason is clinical rather than administrative.
Most are obtained by trained non clinical staff working from structured intake information and the payer's published criteria. The clinical judgement stays with your treating clinician, who we involve in two specific places: building the evidence for requests that turn on clinical criteria, and speaking during a peer to peer. We do not rehearse or replace your clinicians, and we do not write clinical justification without their input.
Sometimes, and it depends entirely on the payer. Some allow retrospective requests inside a short window when the service was urgent or the authorisation requirement was not knowable in advance. Others refuse outright and treat the absence as final. We attempt the ones with a reasonable chance, tell you plainly when a request has no path, and focus the effort on preventing the next occurrence instead of chasing the last one.
It sits upstream of them. Authorisation work produces two things the billing team needs: a decision that a service is covered, and an authorisation number recorded against the encounter. When that number is on the encounter before the claim is created, CO-197 denials largely stop appearing, which removes the highest volume appeal category from their queue and lets them spend that time on claims that were denied for reasons worth arguing.
Stop finding out about authorisations on the denial
Send us your top ten services by volume and your payer mix. We will map which of them need authorisation today, which changed recently and where the gaps are in how your authorisations are tracked, then tell you what we would change first.