Short answer: A prior authorization (PA) specialist gets payer approval before services that require it: checking requirements, assembling documentation, submitting and following up, and tracking approvals, denials, expirations and visit limits. Prior authorization outsourcing hands that queue to an outside team, either a PA company that runs the process or dedicated remote specialists who work in your systems. Either way, the workload is heavy: physicians in an AMA survey reported 39 PA requests per physician per week.
Prior authorization is one of the most time-consuming administrative tasks in a practice, and when it goes wrong it shows up as delayed care and denied claims. This page covers what a PA specialist does, what changed under the CMS prior authorization rule, and how prior authorization outsourcing works so you can compare options. It's part of our revenue cycle management staffing series.
How big the PA workload is
In an AMA survey of 1,000 physicians conducted in late 2024, physicians reported completing an average of 39 prior authorizations per physician per week. Physicians and their staff spent about 13 hours a week on PA, and 40% said they have staff who work exclusively on it (AMA). PA also drives denials: in a 2025 vendor survey of billing professionals, 31% cited prior authorization or referral issues as a common denial reason (Tebra).
What a prior authorization specialist does
- Identifies requirements: checks whether the service, drug or procedure needs authorization for the patient's specific plan.
- Gathers documentation: collects the clinical notes, test results and codes the payer requires, working with clinical staff.
- Submits the request through the payer's portal, an electronic workflow, fax or phone.
- Follows up on pending requests and responds to requests for more information.
- Records the outcome: authorization number, approved units or visits, dates and conditions.
- Handles denials: routes them for peer-to-peer review or appeal, with deadlines noted.
- Tracks expirations and limits so renewals go in before care is interrupted.
What changed: CMS-0057-F
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) applies to impacted payers, including Medicare Advantage organizations, state Medicaid and CHIP programs and certain other plans. Under the rule, these payers must send decisions within 72 hours for expedited requests and seven calendar days for standard requests, starting in 2026, and must give a specific reason for denials. Payers must also build prior authorization APIs by January 1, 2027. The rule excludes drugs (CMS fact sheet).
Faster decisions help, but they don't remove the work of preparing complete requests, tracking them and acting on denials. Our insurance verification guide covers the full front-end workflow.
Appeals are worth tracking
KFF data cited by the AMA shows that in 2023, Medicare Advantage enrollees or providers appealed only 11.7% of PA denials, but 81.7% of appeals were fully or partially overturned (AMA). A specialist who flags appealable denials quickly, with the deadline, gives clinicians the chance to act. Denials for missing authorization often appear on the remittance as CARC 197.
Prior authorization outsourcing: how it works
There are two common ways to outsource PA:
| Prior authorization company | Dedicated remote PA specialists | |
|---|---|---|
| Who directs the work | Vendor, using its process | You, in your systems and workflows |
| Typical pricing | Per authorization or monthly fee | Monthly or hourly per staff member |
| Systems | Vendor platform or your portals | Your EHR, PM system and payer portals |
| Visibility | Vendor reports | Your own queues and reports |
| Good fit | Low or unpredictable volume | Steady volume; specialty groups; treatment centers; billing companies |
Whichever model you choose, write down the handoff: how orders reach the PA team, which clinical documents they can access, how approvals are recorded so they flow onto claims, and who handles peer-to-peer requests.
What to ask a prior authorization outsourcing partner
- Which payers and specialties do your staff work with regularly?
- How will orders reach you, and what's the turnaround from order to submission?
- How are authorization numbers, units and dates recorded so billing can use them?
- Who handles requests for more information and peer-to-peer scheduling?
- What reports will we get (pending, approved, denied, appealed, by payer)?
- Will you sign a BAA before any PHI access, and what access controls do you use?
- What happens to our data if we end the relationship?
Skills to hire for
- Knowledge of payer PA rules for your specialty and main payers
- Comfort reading clinical documentation and matching it to payer criteria
- Payer portal experience and organized follow-up
- Accurate tracking of authorization numbers, units and dates
- Clear communication with clinicians, front desk and billing
- Training on HIPAA and minimum necessary access
Measuring the PA function
- Requests submitted, pending and resolved each week
- Average time from order to submission
- Approvals, denials and appeals, by payer
- Claims denied for missing or mismatched authorization (should trend down)
- Authorizations renewed before expiration
HIPAA
PA work involves clinical information, so a BAA must be in place before any outside specialist has access (HHS). Alliance Global Solutions signs a business associate agreement (BAA) with each client before any of its staff access protected health information. There is no official "HIPAA certification"; see our HIPAA guide for the safeguards to ask about.
Getting help
For high-volume specialties and treatment centers, a dedicated PA specialist often frees front-desk and clinical time (see our behavioral health billing guide). Alliance Global Solutions operates this site and is currently our only approved vendor; see its featured vendor profile. You can read about its medical billing staff or its call center and customer service staff. To talk through PA volume, request help; your request may be referred to Alliance Global Solutions.
Technology
CMS-0057-F requires impacted payers to support prior authorization APIs by January 1, 2027, to decide expedited requests within 72 hours and standard requests within seven calendar days, and to give a specific reason for denials (CMS). Electronic PA will cut some portal and fax work, but specialists will still gather documentation and handle peer-to-peer and appeal steps. Alliance Global Solutions helps clients set up AI assistant workflows alongside their dedicated staff.
FAQ
What does a prior authorization specialist do?
Checks whether services need payer approval, gathers documentation, submits requests, follows up, records approvals and tracks expirations, and routes denials for peer-to-peer review or appeal.
What is prior authorization outsourcing?
Handing the PA queue to an outside team, either a prior authorization company that runs the process (often priced per authorization) or dedicated remote specialists who work in your systems (priced per staff member).
How many prior authorizations do practices handle?
Physicians in an AMA survey conducted in late 2024 reported an average of 39 prior authorizations per physician per week, with about 13 hours of physician and staff time spent on them.
What are the CMS-0057-F decision timeframes?
For impacted payers, decisions within 72 hours for expedited requests and seven calendar days for standard requests, plus a specific reason for denials. Drugs are excluded.
Are prior authorization denials worth appealing?
Often. KFF data cited by the AMA shows 81.7% of Medicare Advantage PA denials that were appealed in 2023 were fully or partially overturned, though only 11.7% were appealed.