We spent two days sitting with the administrative team at a 6-physician orthopedic practice outside Boston — not a clinic we work with commercially, just one that agreed to let us observe their PA queue in exchange for a workflow analysis writeup. What we saw confirmed a lot of what we'd heard anecdotally, but seeing it in real time made the inefficiencies impossible to dismiss as edge cases.
This is a walkthrough of what a single prior authorization request actually looks like, step by step, from the moment a patient referral arrives to the moment the payer renders a decision. We're not describing what best practice looks like. We're describing what typical looks like — because that's the baseline anyone building in this space has to be honest about.
Step 1: The Referral Arrives (and Gets Triaged)
An orthopedic consult arrives from a primary care physician, usually by fax or through the practice's EHR inbox via Direct messaging. The referral coordinator — one person managing this intake for all six physicians — opens it, confirms the patient isn't already in the system, and checks the insurance card on file or calls eligibility through the clearinghouse.
That eligibility check takes three to eight minutes. It's not the check itself that's slow — most clearinghouses return a response in under 30 seconds — it's everything around it: navigating to the right portal, logging in, entering the patient identifiers, and interpreting the response correctly. Medicare Advantage plans in particular return eligibility summaries that require knowing which benefit tier the patient falls under before you can tell whether the requested service (say, CPT 27447, total knee arthroplasty) actually requires prior auth under that plan this year.
The coordinator at this practice keeps a printed reference sheet for the 14 payers she handles regularly. It was last updated in November. Two payers had changed their PA requirement thresholds since then, and she didn't know it yet.
Step 2: Building the PA Request (The Slow Part)
Once the coordinator determines a PA is required, she pulls the clinical documentation. This is where most of the calendar time accumulates — not because the task is difficult, but because the inputs are scattered.
For a knee arthroplasty case, a typical PA submission for a commercial payer or Medicare Advantage plan requires: the referring physician's notes (often incomplete or in a format the payer won't accept as-is), imaging reports (which may be attached to the referral or may need to be requested from the imaging center), a history of conservative treatment including physical therapy records and prior medication trials, the treating physician's clinical rationale, and the correct ICD-10 diagnosis codes (in this case, typically M17.11 or M17.12 for primary osteoarthritis of the knee, plus any relevant comorbidities).
Gathering these takes, on average, 45 to 90 minutes per request. The physical therapy records are almost always the bottleneck — they come from third-party PT providers who respond by fax, sometimes within hours, sometimes after two follow-up calls over three days.
The coordinator drafts the medical necessity letter herself using a template built by the practice's billing manager four years ago. It's a reasonable template, but it doesn't adapt to payer-specific criteria. UnitedHealthcare uses different medical necessity criteria for TKA than Aetna does. The coordinator doesn't have time to cross-reference both payers' clinical policies before drafting, so she submits the same general-purpose letter to both and hopes the clinical detail is sufficient.
Step 3: Submission and the Payer Portal
Most commercial payers now accept electronic prior authorization through their web portals, and some support X12 278 transaction sets through the practice's clearinghouse — a meaningful step forward from the all-fax era. But "electronic" doesn't mean "easy." The coordinator at this practice logs into six different payer portals to submit PAs, each with its own authentication flow, question set, and document upload interface.
The Humana portal times out after 20 minutes of inactivity and loses form progress. The BCBS portal requires clinical attachments to be uploaded as individual PDFs under 5MB each. A 40-page PT record has to be split manually before upload. These aren't catastrophic problems — they're friction, and friction compounds across 12 to 18 PA submissions per week.
Turnaround on submitted PAs ranges from same-day to 14 calendar days, depending on the payer and whether the request triggers a clinical peer-to-peer review. Medicare Advantage plans are required under CMS rules to respond within 72 hours for urgent cases and 14 days for standard, but in practice the variance within those windows is large.
Step 4: The Decision — and What Happens Next
Approximately 30% of first-submission PAs at this practice are denied or returned for additional information. That number tracks with AMA survey data showing that roughly 1 in 4 PA requests requires a follow-up submission or appeal, and it's higher for orthopedic procedures than for primary care services.
When a denial arrives, the coordinator flags it for the physician, who reviews and typically dictates an appeal letter or requests a peer-to-peer call with the payer's medical director. Peer-to-peer calls take 15 to 30 minutes of physician time, scheduled one to three days out. The appeal, if submitted in writing, requires assembling the original submission plus any additional clinical evidence — sometimes a second opinion report, sometimes a letter of medical necessity with more specific ICD-10 detail about severity or prior treatment failure.
Successful appeals usually require specificity the original submission lacked. M17.11 alone isn't enough if the payer's criteria require documented failure of at least six weeks of conservative management plus radiographic evidence of joint space narrowing. If the original medical necessity letter didn't include both explicitly, it gets denied on criteria even when the clinical case is clear.
Where the Time Actually Goes
We tracked time-on-task for each stage across a two-day observation period. The breakdown was roughly: eligibility verification and PA determination, 8–12 minutes per case; clinical record gathering, 45–90 minutes per case (90% of which was waiting or following up, not actual review); submission, 20–35 minutes per case; denial response and appeal prep, 60–120 minutes per denial.
The coordinator handled 14 PA-related tasks across two days, not counting phone calls to payers for status checks. Her total documentation and submission time was approximately 9 hours out of a 16-hour observed window. The rest was phone calls, patient scheduling, and coverage for the front desk.
We're not saying practices need to hire another coordinator to solve this — adding headcount is one option, but it doesn't fix the underlying structure. The more durable fix is reducing the per-request time investment through better documentation integration and payer-specific criteria awareness at the point of drafting, before the first submission goes out.
The Structural Problem Underneath the Workflow Problem
The deeper issue isn't that any individual step is uniquely difficult. It's that each step is disconnected from the others. The eligibility check doesn't automatically trigger a PA requirement lookup. The PA requirement lookup doesn't auto-populate the payer's clinical criteria. The clinical criteria don't connect to the patient's existing documentation to flag what's present and what's missing before the coordinator starts drafting.
That disconnection means the coordinator has to hold the entire context of the case in working memory across multiple systems, portal sessions, and hours of waiting. When she's managing 15 open PA requests simultaneously — some at the submission stage, some waiting on PT records, some in appeal — the cognitive load creates errors: wrong ICD-10 codes, missing attachments, form submissions to the wrong payer portal.
Electronic PA mandates under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) will eventually push more payers toward standardized X12 278 transaction sets and FHIR-based APIs. That standardization will help. But it won't fix the documentation quality problem — it'll just move the bottleneck from portal navigation to upstream clinical record completeness. Practices that solve the upstream problem now will benefit most from the infrastructure improvements downstream.
What a Cleaner Queue Looks Like
We've thought a lot about what the same workflow looks like with better tooling in place. Not theoretical tooling — concrete changes to how information moves between the clinical encounter, the PA determination step, and the submission document.
The highest-impact intervention isn't automating the payer portal interaction, though that matters too. It's getting the clinical documentation right before the first submission. If the ambient encounter note captures the conservative treatment history, the relevant ICD-10 codes, and the clinical rationale for the procedure in a format that maps directly to the payer's medical necessity criteria, the coordinator's job shifts from drafting and gathering to reviewing and submitting.
That shift — from creator to reviewer — cuts the high-variance 45-to-90-minute record gathering step down significantly. More importantly, it cuts the 30% first-submission denial rate, which is where the real cost lives. A successful first-pass submission doesn't just save the coordinator's appeal time. It moves the patient's procedure forward by 10 to 14 days.
The practices we're working with that have the most to gain from PA automation aren't the ones with the most chaotic queues. They're the ones where the coordinator is competent and organized, but is constrained by the quality and accessibility of clinical documentation upstream. Competence without good inputs produces better-than-average results; competence with good inputs produces a fundamentally different queue.