Reducing Delays and Denials Before They Happen

By Andy Schachtel, CEO of Sourcefit | Global Talent and Elevated Outsourcing

Key Takeaways

• Prior authorization is the single biggest administrative burden in healthcare: the AMA reports that 94 percent of physicians experience care delays due to prior auth, and the average physician practice spends 14 hours per week on prior auth activities.
• Offshore prior authorization teams cost 55 to 65 percent less than domestic staff while reducing turnaround times because they can work on submissions during US off-hours, getting approvals back faster.
• The prior auth workflow is highly process-driven (submit request, provide clinical documentation, follow up, appeal if denied) and follows payer-specific but documentable rules, making it well suited for trained offshore teams.
• Denial prevention through complete, accurate initial submissions is more cost-effective than denial management after the fact. Offshore teams trained on payer-specific requirements achieve first-pass approval rates of 85 to 90 percent.

Why Is Prior Authorization Such a Massive Problem?

Prior authorization was designed as a cost containment tool: require providers to get approval before delivering certain services to ensure medical necessity. In practice, it has become an administrative burden that delays patient care, consumes clinical resources, and costs the healthcare system billions of dollars annually.

The numbers are staggering. According to the American Medical Association, 94 percent of physicians report that prior auth delays necessary care. 80 percent report that prior auth can lead to treatment abandonment (patients giving up because the approval takes too long). The average physician practice dedicates 14 hours per week, nearly two full-time equivalent positions, to prior authorization activities.

The burden falls disproportionately on clinical staff. Nurses and medical assistants who should be providing patient care instead spend their time on hold with insurance companies, filling out forms, and tracking submission statuses. Physicians review and sign clinical documentation for prior auth requests that interrupt their patient schedules.

This is a problem that outsourcing solves directly. Prior authorization is process-driven, payer-specific, and high-volume. It requires trained staff, but it does not require those staff to be clinicians or to be physically present in the practice. An offshore team dedicated to prior auth frees clinical staff to do clinical work while improving turnaround times and approval rates.

What Does the Prior Authorization Workflow Look Like?

The workflow begins when a provider determines that a patient needs a service, procedure, or medication that requires prior authorization. The prior auth team verifies the requirement (not all services require auth from all payers), gathers the necessary clinical documentation, and submits the request through the payer’s designated channel (portal, fax, phone, or electronic prior auth).

After submission, the payer reviews the request against their medical necessity criteria. This review can take anywhere from 24 hours for urgent requests to 14 business days for standard requests. During this period, the prior auth team monitors the status, responds to requests for additional information, and communicates timelines to the ordering provider and patient.

If approved, the authorization number and terms are documented in the patient’s record and communicated to the scheduling or dispensing team. If denied, the prior auth team reviews the denial reason, determines whether an appeal is warranted, gathers additional clinical documentation if needed, and submits the appeal within the payer’s required timeline.

Each step in this workflow is documentable and repeatable. The payer-specific variations (which portal to use, what documentation to include, what criteria to meet) are learnable. An offshore team trained on the specific payers and services a practice encounters handles this workflow as effectively as a domestic team, at a fraction of the cost.

How Do Offshore Teams Improve Prior Auth Turnaround Times?

Time zone differences, which are sometimes cited as a disadvantage of offshore outsourcing, work in prior auth’s favor. A Philippines-based team starts their workday when the US day ends. They prepare and submit prior auth requests during US evening hours. By the time the payer processes the request the next US business day, the submission is already in the queue. For payers that process requests within 24 to 48 hours, this effectively eliminates one day of waiting.

Dedicated focus is the other advantage. Clinical staff in a practice juggle prior auth alongside patient care, phone calls, charting, and dozens of other responsibilities. Prior auth tasks get pushed to the end of the day, batched, and sometimes delayed. An offshore team whose sole job is prior authorization processes requests as they come in, follows up systematically, and does not set tasks aside because a patient walked into the clinic.

The result is measurably faster turnaround. Practices that move prior auth to dedicated offshore teams typically see a 30 to 50 percent reduction in average turnaround time, not because the payers approve faster, but because the submissions are completed and submitted faster, follow-ups happen on schedule, and additional documentation requests are fulfilled within hours rather than days.

What Training Does an Offshore Prior Auth Team Need?

Training covers four areas. First, the clinical vocabulary and documentation required to understand prior auth requests. The team does not need to be clinicians, but they need to understand CPT and HCPCS codes, ICD-10 diagnosis codes, and the relationship between the diagnosis and the requested service (medical necessity logic).

Second, payer-specific submission requirements. Each major payer (UnitedHealthcare, Anthem/Elevance, Aetna/CVS Health, Cigna, Humana, and regional Blues plans) has different submission portals, documentation requirements, and medical necessity criteria. The team must be trained on the specific payers the practice encounters most frequently.

Third, EHR and practice management system navigation. The team accesses clinical documentation from the EHR (Epic, Cerner, athenahealth, eClinicalWorks) and submits authorizations through payer portals or electronic prior auth (ePA) platforms. System training is essential for efficient workflow.

Fourth, denial and appeal management. When a request is denied, the team must understand the denial reason, determine whether the denial is clinically appropriate or an administrative error, and initiate the appeal process with the correct documentation. Clinical denial appeals require physician involvement; administrative denial appeals can often be handled entirely by the offshore team.

Training takes 4 to 6 weeks for a team handling a typical multi-payer practice. Practices with unusually complex prior auth requirements (specialty pharmacy, genetic testing, advanced imaging) may require 6 to 8 weeks.

How Should Healthcare Organizations Structure Prior Auth Outsourcing?

Start by quantifying the current burden. Count the number of prior auth requests per week, the average turnaround time, the approval rate on first submission, and the number of staff hours dedicated to prior auth activities. This baseline allows you to measure the impact of outsourcing objectively.

Assign a clinical liaison who bridges the offshore team and the clinical staff. When the offshore team needs a physician to provide clinical documentation, sign a peer-to-peer review request, or review a denial for clinical merit, the liaison coordinates quickly. This role is typically a nurse or medical assistant who spends 2 to 4 hours per day on liaison activities.

Build payer-specific playbooks. For each major payer, document the submission portal, required documentation, medical necessity criteria for common services, turnaround time expectations, and appeal procedures. These playbooks become the offshore team’s operational guide and are updated as payer requirements change.

Track first-pass approval rates by payer. A well-trained team should achieve 85 to 90 percent first-pass approval on standard requests. If the rate drops below 80 percent for a specific payer, investigate whether the payer has changed its criteria, whether the documentation is insufficient, or whether the team needs additional training on that payer’s requirements.

Frequently Asked Questions

Do offshore prior auth teams need clinical credentials?

No. Prior authorization is an administrative function that requires training on clinical vocabulary, coding, and payer requirements, but it does not require clinical licensure. The offshore team handles submission, tracking, follow-up, and administrative appeals. When a payer requires a physician peer-to-peer review or clinical attestation, that step is coordinated through a domestic clinical liaison.

How do offshore teams handle payer phone calls for prior auth?

Offshore teams use VOIP systems with US phone numbers to call payer authorization lines. Filipino prior auth specialists are familiar with payer IVR systems and agent interactions. For peer-to-peer reviews (where a physician must speak directly with the payer’s medical director), the offshore team schedules the call and prepares the documentation; the physician handles the call itself.

Can offshore teams use electronic prior authorization (ePA) platforms?

Yes. ePA platforms like CoverMyMeds, SureScripts, and Availity are cloud-based and accessible from any location with appropriate credentials. Offshore teams submit electronic prior auth requests through these platforms, track status, and process responses. ePA is actually easier for offshore teams than phone or fax-based submissions because it eliminates the need for real-time phone interaction with payers.

What happens when a prior auth expires before the patient receives care?

Prior authorizations have expiration dates (typically 30 to 90 days depending on the payer and service). The offshore team tracks expiration dates and initiates renewal requests before they lapse. This proactive tracking is one of the areas where dedicated offshore teams outperform clinical staff who are managing prior auth as a secondary responsibility.

How do you measure the ROI of outsourcing prior authorization?

Measure four things: reduction in staff hours dedicated to prior auth (multiply hours saved by the hourly cost of clinical staff), reduction in average turnaround time (faster auth means faster scheduling and revenue recognition), improvement in first-pass approval rate (fewer denials means less rework and fewer lost authorizations), and the direct cost comparison (offshore team cost versus the fully loaded cost of the domestic staff previously handling prior auth). Most organizations see positive ROI within 3 to 4 months.

To learn more about how SourceCycle can help you build a dedicated offshore prior authorization team that reduces delays, improves approval rates, and frees your clinical staff, visit sourcecycle.com or contact our team for a consultation.

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