62% of Patients Give Up on Care Due to Prior Authorization Delays

A national survey of 500 U.S. adults, commissioned by Penguin Ai, reveals that a significant portion of patients and caregivers are giving up on medical care due to prior authorization delays and denials. According to the findings, 62% of respondents who faced a delay, denial, or medication restriction say they have given up on care because fighting their insurer wasn't worth it. Across the full sample, 48% of respondents reported the same.

Every respondent needed at least one prior authorization for themselves or a family member in the past two years. The survey highlights that most patients and caregivers wait four days or longer for a prior authorization decision. Only 14% of respondents received a same-day decision, with the most common wait being four to seven days (29%). About one in three respondents waited a week or longer or were still waiting when they took the survey.

Denials and delays led 36% of respondents to pay out of pocket and 21% to skip care entirely. The outcomes after a denial or delay were varied, with 32% delaying care, 17% going to an emergency room or urgent care instead, and 13% reporting that their symptoms or health got worse. Only 20% of respondents reported none of these outcomes.

In response to these challenges, 87% of respondents would support AI that speeds approvals and makes them more accurate. Specifically, 49% of those respondents would support AI with human oversight. The survey also found that 62% of respondents who faced a prior authorization delay, denial, or medication restriction say they have given up on care because fighting their insurer wasn't worth it. Across the full sample, 48% say the same.

Among those who appealed an insurer's decision, 47% had the decision overturned, while 24% saw it upheld. Another 20% were still waiting for an outcome, and 8% gave up partway through. Patients who appeal win nearly half the time, but the process is time-consuming and stressful. Seventy percent of respondents spent at least an hour on phone calls and paperwork with their insurer, and 16% spent more than five hours. Nearly half (49%) rated their stress a 4 or 5 out of 5.

Penguin Ai's Intelligent UM prepares each prior authorization case with the clinical documentation mapped to medical necessity criteria, and a clinician signs off on every recommendation before it issues. Appeal outcomes feed back into the review process so health plans can correct the criteria and documentation problems behind overturned decisions.