In August, we released The truth about prior authorization, our inaugural report analyzing data collected directly from payors to understand whether – and how – efforts to improve healthcare’s “burden turned nightmare” have had any effect. 

As we wrote in the report, no one likes prior auth; patients, providers, and payors have all spoken out about the need for reform. And because transparency is the first step toward driving the real change everyone in the ecosystem seeks, we’re continuing to dive into the trends we can uncover in the data collected by Infinitus AI agents.

Today, we’re going a level deeper to understand the differences between how major medical insurance’s handling of prior auth differs from pharmacy benefit managers (PBMs). 

Turnaround time: How long does a prior auth take?

Aside from the results of the determination itself, the time it takes for a payor to return a prior authorization decision is arguably the most important part. And it turns out there is a difference in how quickly PBMs handle prior authorization compared to major medical insurance: PBMs appear to be more efficient. 

In fact, 68.8% of the time, PBMs return prior authorization determinations in five days or less, compared to 42.4% for major medical insurance companies. PBMs return over a quarter of prior authorization determinations in less than 48 hours.

A graph showing the average prior authorization turnaround time for major medical vs. PBM.

Notification of determination: Does the fax still rule?

Fax, phone, and mail were the top three methods of prior auth determination notification reported by major medical insurance. For PBMs, email joined phone and fax in the top three, replacing traditional mail. 

Most notably, fax was No. 1 for both types of payors – yes, even in 2024. The outdated fax machine continues to play a huge role in the transfer of healthcare data, even in our digital era.

A graph showing the top methods for notification of prior authorization determination, major medical vs. PBM.

Step therapy: How often is it required?

As we revealed in our original report, less than a third of the calls the Infinitus AI agent made resulted in step therapy requirements. However, when drilled down to PBM vs. major medical insurance, the results are telling. Step therapy was only required by PBMs 5% of the time in 2024, vs. nearly 40% for major medical.

A graph showing the percentage of the time step therapy is required for major medical (39% of the time) vs. PBM (5% of the time).

Renewal processes: Do they exist?

Patients with ongoing treatment will likely need a prior authorization at least once every year. And despite widespread agreement that continuity of care is critical, prior auth renewal processes are anything but a guarantee.

Interestingly, 90% of PBMs reported that prior authorization renewal processes existed in 2024, compared to less than half of the time for major medical insurance.

A graph showing the percentage of the time major medical (43%) vs. PBMs (90%) say a renewal process for a prior authorization exists.

To see more trends in prior authorization data collected directly from payors, read the full 2024 edition of The truth about prior authorization or reach out to our team today.