Prior Authorization Services at 9.0% of Insurance Payments

When to outsource prior authorization

Hand authorization work to us when it starts eating the schedule: staff refreshing payer portals, visits moved because an approval had not come back, or claims denied because an approval lapsed before the last session. The load is real. Physicians in the AMA’s 2025 prior authorization survey reported completing an average of 40 prior authorizations a week, at 13 hours of physician and staff time, and 40% employ staff dedicated exclusively to the task.

We take that queue over as part of your billing, not as a separate desk. Coverage checks before the visit run through eligibility verification, and a claim the payer has already denied goes to denial management. The authorization sits between them, run by the team that bills the visit.

What our prior authorization service covers, and what you keep

Every request keeps its payer reference, the open question and the payer’s decision in one record your staff can read. The table shows who owns each step.

What stays with your clinicians

Your clinicians keep every clinical and treatment decision and make the clinical case on any peer-to-peer call. We assemble what is already in the chart and send gaps back to the clinician; we never write documentation to make a request fit. We check every code against your clinician's documentation and never change a code without the clinician's sign-off. Code questions go to our medical coding team under the same plan.

How we run each authorization request

Each request moves through the same six steps, and each step has one owner, so a stalled case shows exactly who it waits on: us, the payer or your clinician.

We record each decision in the payer’s own terms, not a bare “approved” label: Aetna says an approval covers only the service or supply named (2026 participating provider list) and that a tracking number assigned during record review is not an approval (precertification lists).

When the payer says no, who does what

We log the decision, its stated reason and each deadline the payer gives, then send it to your clinician, with the request and notes it was built from. Your clinician decides whether to seek a peer-to-peer call or reconsideration and makes the clinical case; we never argue it for them. In the AMA’s 2025 survey, only 21% of physicians always appeal an adverse decision, and 52% of those who do not cite insufficient staff resources or time. We keep the deadlines in view so a denied request is not lost to staff time.

Read the workflow as text

1. Check the list — Member's payer and plan list checked before the visit is booked. Owner: Our team.
2. Build the packet — Clinician's notes assembled; any gaps sent back to the clinician. Owner: Our team + clinician.
3. Submit and log — Sent through the payer's channel; reference and date saved. Owner: Our team.
4. Follow to decision — Payer questions routed; overdue decisions chased against the payer's clock. Owner: Our team.
5. Record the terms — Approved service, dates, units, provider and location saved. Owner: Our team.
6. Bill and renew — Authorization number on the claim; renewal requested before it ends. Owner: Our billing team.

Where authorizations cost a practice money, and how we handle each

• Checked against the wrong list. UnitedHealthcare says advanced outpatient imaging may need authorization but does not require it for CT, MRI or MRA on its Medicare Advantage and D-SNP plans. We check the member’s own plan list before every request.
• Secondary coverage missed. Aetna requires precertification when it is the primary or the secondary payer. We check both coverages before the visit.
• An approval read too broadly. A changed date, service, provider or location can fall outside what the payer approved. We record those terms with each decision and check the claim against them before it goes out.
• Approvals that lapse mid-treatment. When an approval covers a set number of visits or units, we count usage against it and request renewal before it ends, so a lapse is caught before the last sessions.
• Decisions left waiting. Under CMS-0057-F, Medicare Advantage plans and Medicaid and CHIP programs must decide standard non-drug requests within 7 calendar days and expedited ones within 72 hours from January 1, 2026. We log the clock that applies to each payer and chase overdue decisions instead of waiting.
• A claim sent without the number. Our billing team puts the authorization number on the claim it covers. If a payer still denies the claim, denial management works it.

To find which step in your practice causes each denial, missing authorizations included, see our guide to reducing claim denials.

What prior authorization services cost

Authorization work sits inside our billing plans; we do not sell requests one at a time, because an approval pays off only when the same team bills the visit it covers and works any denial that follows.

Your fee is a percentage of insurance payments posted on claims we submitted or worked, net of payer recoupments and refunds. We take 0% of patient payments, copays and anything your front desk collects. Setup is $0. Invoices 1–3: only percentage fees on that month's insurance payments, plus any statements or add-ons you order. Percentage fees and mailed statements are capped at 9.0% of that month's insurance payments; from invoice 4, the $400 minimum applies even in a month when the cap comes to less. Every size band and plan is on the medical billing rate card.

How we start on your authorization queue

1. You sign the service agreement and a business associate agreement. Billing is a business-associate activity under HHS guidance, so no records move before it.
2. On the kickoff call we list your payers, request types, open requests and approvals that end soon.
3. We log every open request and current approval with its terms and end date.
4. We agree the intake fields and the clinician who answers documentation questions.
5. From go-live, new requests start through us.

Go-live, when your first claims go out, comes within 5 business days of access; any unbilled backlog follows within 10 business days of access. Clock starts with your signed agreement, signed BAA and working system logins; it extends day for day while we wait on access. Moving from another billing company? Here is how a handover to us works.

What we report on your authorizations, and the terms behind it

Your monthly report arrives by the 10th of each month with written definitions. For authorizations it shows:

• Requests sent: new requests and renewals submitted in the month.
• Waiting: open requests, split by whether each waits on us, the payer or your clinician.
• Decisions: approved, partly approved, denied and pending, in the payer’s own wording.
• Ending soon: approvals that end before the next report, with their renewal status.
• Adverse decisions: each denied or partly approved request, with the payer’s reason and deadlines.

We cannot make a payer approve a request; the payer decides. What we guarantee sits on the claims: From go-live, every new claim goes out within 1 business day of complete charge data, and every denial is worked within 2 business days of posting — or $25 comes off your invoice for each late one. Mon–Fri ET business days by your system's timestamps; worked: resubmitted, appealed or returned with the fix; auto-credited; capped at monthly fee; clearinghouse outages excluded. Month to month. Leave with 30 days' written notice. No termination fee. Talk to us about your authorization queue.

Specialty practices whose authorizations we run

• ABA therapy: authorized units tracked against every session claim and renewed before the period ends.
• Physical therapy: approved visits counted as the plan of care runs, with renewal requested before the last one.
• Radiology: advanced imaging checked against the member’s plan before the study is scheduled.
• Cardiology: EP implants, diagnostic caths and stress echoes, which UnitedHealthcare requires authorization for in outpatient and office settings.
• Orthopedics and pain: spine surgery and pain-management injections requested from the surgeon’s notes.
• Neurology: botulinum toxin series, with each patient’s authorization end date checked before the next injection.
• Rheumatology: biologic infusion reauthorizations requested before the current approval ends.
• Medical oncology infused drugs and radiation, including requests a payer routes to its review vendor, as Aetna does for some members.
• Behavioral health: requests checked against the payer’s behavioral health list where it publishes one.

Common questions

How much do prior authorization services cost?

Requests, tracking and renewals come inside Complete RCM at 9.0% of insurance payments, with 0% of patient payments and $0 setup. Full-Service Billing, 5.0% to 8.5%, tracks authorization expiry while your staff submit. See the rate card.

Can we outsource prior authorization without outsourcing our billing?

Not today. We take on authorizations only inside our billing plans, because an approval pays off when the same team bills the visit and works any denial that follows. If you are weighing the whole function, the in-house vs outsourced billing comparison sets out the trade-offs.

Can you guarantee the payer approves our requests?

No. The payer decides, on its own criteria and your clinician’s documentation. We commit to the work we control: requests built from your notes, every decision recorded with its terms, and renewals requested before approvals end, from your clinician’s current documentation. On the claims that follow, the Clock-or-Credit Guarantee applies: Mon–Fri ET business days by your system's timestamps; worked: resubmitted, appealed or returned with the fix; auto-credited; capped at monthly fee; clearinghouse outages excluded.

What do you need from our practice to start?

Sign the service agreement and BAA, give us logins to your practice-management system and clearinghouse, join one 45-minute kickoff call, sign off encounters so charges are complete, and answer our documentation questions within 5 business days. For authorizations, also name the clinician who answers documentation questions and send the open requests and current approvals you track today.

What happens when a payer denies an authorization request?

We log the payer’s reason and every deadline it gives and send the decision to your clinician, with the request and notes behind it. Your clinician decides whether to seek a peer-to-peer call or reconsideration and makes the clinical case; the split is under who does what when the payer says no. If the claim for a delivered service later denies, denial management works it.

Which systems and payer portals does your team work in?

We work inside your existing practice-management system and clearinghouse; tell us which ones and we confirm in writing within 1 business day. We submit through each payer’s own channel, using access your practice authorizes. See systems we work in.

Should we keep prior authorization in-house or outsource it?

Count the hours first: requests per week × minutes per request, including portal checks, payer calls and peer-to-peer scheduling. For example, 25 requests × 30 minutes is 12.5 staff hours a week. Keep it in-house when that fits inside one person’s week and few payers are involved; hand it to us when requests wait on staff time or approvals lapse. Physicians in the AMA’s 2025 survey reported 13 hours of physician and staff time a week.