Suboptimal Clinical and Utilization Decisions Driven by Prior Authorization Constraints

$10,000-$25,000/month in denied claim rework + $7,000-$18,000/month in patient abandonment + $15,000-$40,000/month in relapse-driven emergency visits from premature or downgraded therapy • $10,000-18,000 per case in preventable escalation (outpatient→ED→inpatient) due to treatment delays while awaiting authorization; loss of $100-250/month per Medicaid patient in fragmented outpatient revenue • $10,000-18,000/Medicare beneficiary from preventable hospitalization due to medication inadequacy; Medicare Part B budget absorbs $5,600-9,800 per member per year in preventable acute medical costs from psychiatric medication optimization delays

Administrator maintains informal spreadsheet of which treatment modalities have highest approval rates; relies on billing staff to flag risky authorizations; administrative team uses email threads to discuss which patients to 'discharge early' to avoid denial risk; no formal tracking of foregone revenue from suboptimal service intensity • Administrator maintains spreadsheet of VA authorization timelines; uses email to coordinate with VA liaisons; clinical team tracks via informal notes which treatment modalities have historically faster VA approvals; billing staff maintain phone relationships with VA pre-auth coordinators; staff discuss authorization strategy via huddles before patient encounters • Administrator manually tracks commercial carve-out denial rates in spreadsheet; informal meetings with clinical leadership to discuss 'safer' treatment recommendations; billing team maintains shadow list of which therapies get approved faster; staff use email chains to coordinate which patients to prioritize for authorization to avoid care gaps