Prior authorization was designed as a cost-control tool for payers, but a new systematic review in the American Journal of Managed Care by Virginia Commonwealth University researchers finds it consistently imposes measurable time and labor costs on pharmacies and physician practices.
The review analyzed 14 U.S. and Canadian studies that directly measured time and labor costs associated with drug prior authorization (PA) in outpatient settings. Only studies with real-time, observed measurements of PA activity were included. Surveys, recall-based estimates, modeling studies, and non-drug services were excluded.
Across physician practice settings, completing a single drug prior authorization typically took 25 to 64 minutes, depending on workflow design, staffing mix and practice type. Some studies reported lower averages around 16 to 25 minutes, while higher-burden settings, including specialty clinics, reached 46 to 64 minutes per PA. In more extreme cases, particularly for complex therapies, reported averages reached 100 minutes, with ranges extending as high as 200 minutes per authorization.
Pharmacy-based studies showed a narrower but still meaningful range. In health system–based prior authorization clinics, average completion times were generally 15 to 24 minutes per PA, with one study reporting 74 minutes for appealed authorizations, reflecting the added burden of escalation and payer denial processes.
Labor costs tracked closely with time burden but varied by staffing model and setting. In physician practices, per-authorization costs generally ranged from $21 to $49, with lower estimates tied to leaner workflows and higher estimates reflecting multistaff involvement and inclusion of opportunity cost. In pharmacy-based PA clinics, costs ranged from approximately $15 to $63 per authorization, depending on whether specialty drugs, implementation costs or broader staffing overhead were included.
The review also highlights how fragmented measurement remains. Some studies captured only portions of the PA workflow, such as per "event form" rather than per completed authorization, while others omitted physician time entirely or failed to distinguish between drug and non-drug PAs. As a result, comparability across studies remains limited even when point estimates appear similar, the review found.
Most evidence came from hospital-affiliated outpatient clinics, with relatively few studies in private community practice settings. Only a small number of studies used multisite or broader geographic samples, limiting generalizability to national practice patterns.
No studies measured prior authorization costs in community, mail-order or specialty pharmacies, even though these channels handle the majority of prescription dispensing. The review notes this as a major gap in the literature, particularly given the differing workflows and payer interactions in those settings compared to health system–based pharmacy PA clinics.
While the review focused strictly on financial costs rather than clinical outcomes, it drew on prior research linking PA requirements to administrative strain, delayed medication initiation and clinician burnout. One cited survey found that 89% of physicians report PA contributes to burnout, underscoring the operational burden beyond direct labor costs.
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