Prior authorization: the weekly load, and how enrollment choices change it. Each payer you join hands you its list.

Practices complete 40 prior authorization requests per physician, per week, by the AMA's count.^A Physicians and their staff spend an average of 13 hours a week on them. That figure counts the physician's own time alongside the staff's. The survey asked 1,000 physicians.

The number is heavy on its own. What it hides is where the requests come from. A practice does not choose to face 40 of them. It takes them on one payer contract at a time.

The count is per physician.

The AMA counts requests per physician, so the load grows with every physician the practice adds. A new provider brings their own patients, their own orders and their own requests, and each of those goes to whichever plan the patient carries.

The same survey found that 40% of physicians have staff who work exclusively on prior authorizations.^A In a practice without that person, the requests still get made. They get made between other jobs, by whoever is at the desk, and some of them get made after the visit instead of before it.

Every payer brings its own list.

There is no single list of services that need approval. Each payer keeps its own, and there is no universal code list to check against. Enrollment works the same way. Medicare runs through PECOS, each state Medicaid program runs its own, and each commercial payer takes a separate application for each provider.^B

Put those two facts side by side and the link is plain. The list of payers a practice enrolls with is the list of rulebooks its staff works from every week. A Medicare Advantage plan and traditional Medicare are separate enrollments with separate rules, even for the same patient in the same county. A Medicaid managed-care plan is its own rulebook again.

This is the part of the load a practice decides. It decides it when it picks which plans to join, which lines of business to accept within a payer, and which of its services it plans to bill to each one. Patient demand and the fee schedule drive that choice. The authorization rules for the practice's own services belong in it too.

Declining a plan is a patient-access decision as much as a workload one, and that call stays with the practice. It is better made with each plan's list in hand. When we run a practice's billing, that check is ours: which services each plan wants approved first, for every payer the practice is enrolled with.

Some rules arrive with the enrollment type.

How a practice enrolls can decide what it has to prove before a claim pays. The clearest case is the dental sleep appliance. Under the Medicare coverage rule for oral appliances, the device is provided and billed by a licensed dentist.^C The dentist who provides it has to be the one enrolled as the medical equipment supplier. Medicare does not accept the appliance billed under another supplier's number.

The same rule sets the paperwork. It calls for an evaluation by the treating practitioner, who may be a physician, nurse practitioner, clinical nurse specialist or physician assistant, and a covered sleep test that meets set severity thresholds.^C A dental practice that enrolls as a supplier takes on that file for every appliance it bills. Commercial medical plans set their own rules for the same device, and those differ from Medicare's.

Medical services inside an aesthetics practice run into the same pattern from the other side. For hormone therapy tied to a covered diagnosis, prior authorization and step therapy are common payer requirements.^D A practice that adds a medical director and starts billing those visits has added a line of approvals to its week, one payer at a time.

A missing approval shows up as a denial.

When a request is made late or not at all, the cost lands in billing, not at the front desk. The visit happened and the claim goes out. The payer denies it for the missing approval, and someone has to decide whether it can be fixed after the fact.

Denials are common enough on their own. In Experian Health's survey of 250 revenue-cycle leaders, 41% said at least one in ten of their claims is denied.^E Read that as direction, not as a small-practice figure. The respondents lean toward larger organizations, and Experian sells revenue-cycle software. The survey does not break out how many of those denials trace to authorization. The mechanics do not need a survey. An approval that was never requested is a claim that was never going to pay as billed.

What we run.

Authorizations sit inside our billing and revenue cycle service. We check which services each plan wants approved first, request the approval with the documentation the plan asks for, and log the approval number against the visit. When a claim comes back denied for authorization anyway, we work the appeal with that record in hand. Where each request stands goes on the Friday board with everything else.

For a practice that is not enrolled yet, the order matters. The Payer Enrollment Sprint files the applications. The list of payers it files with is the same list that will set the approval work once claims start. Bring the services you plan to bill to the free review, and we read the two together before anything is filed.