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We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com. Back to Healio Key takeaways: Approximately 80% of appeals to prior authorization denials are ultimately approved. Ongoing effort is required at every step of the process. FORT LAUDERDALE, Fla. \u2014 Appealing claims denials in the prior authorization process requires continuous pressure, according to a presenter at the 2026 Rheumatology Nurses Society annual conference. \u201cI am not going to pretend in 45 minutes to tell you everything you need to know about prior authorizations,\u201d Katie Taylor, CMPM, CRH-c, CRMS, an administrator with Carondelet Rheumatology, in Kansas City, Missouri, told attendees. \u201cIt is not fun and there are no shortcuts.\u201d
In an interview with Healio, Taylor described the prior authorization process as a \u201cbeast of burden\u201d for rheumatology doctors, nurses and administrators alike. \u201cYou can never stop fighting,\u201d she said. \u201cYou have to keep moving forward for the benefit of your patients.\u201d Rheumatology has the second costliest medications of any health care specialty, behind oncology, according to Taylor. \u201cOur patients are on very expensive medications and they are on them for life,\u201d she said. \u201cWe are a big spend.\u201d Insurance companies do not want to spend the money for these medications, Taylor added. \u201cThey try to get out of that,\u201d she said. Understanding this fundamental challenge is the first step to being effective at securing prior authorizations for rheumatology patients. The next step for any practice is to determine how to handle prior authorizations. According to Taylor, between 40% and 50% of practices will have a staff member dedicated to communicating with insurance companies. Other practices divide these responsibilities among staff, she added. Third-party companies also offer services interfacing with prior authorizations. However, individual practices should weigh the cost-benefit ratio of these vendors, according to Taylor. \u201cIt will only decrease your workload by about 13%,\u201d she said. Additionally, practices using third-party vendors to help with prior authorizations should be aware of privacy and HIPAA laws, Taylor said. Regardless of whether the prior authorizations are handled by one person, a committee or a third-party service, Taylor said the key element is continued pressure. \u201cAround 80% of appeals after a patient is denied medication get approved,\u201d she told Healio. \u201cThere is no right or wrong way to do it.\u201d Attention to detail is paramount. According to Taylor, insurance carriers will deny claims if a single field in the application form is not filled out correctly. \u201cAlso, treatments are evolving,\u201d she said. \u201cWhen new therapies come out, the formularies can change.\u201d Taylor encouraged attendees to document every step of the request, denial and appeal of the prior authorization process for every patient. Learning from past denials and mistakes can save time for the next step. \u201cGet a method to your madness,\u201d she said. \u201cYou are never going to be able to do it the same way for every patient, but you can establish a roadmap.\u201d Understanding the difference between an exception and appeal is also critical. An exception is a special request for coverage, while an appeal is reconsideration of a denied claim, Taylor said. \u201cWe start writing our appeals before we even start the case,\u201d she added. Insurance companies are increasingly using AI for denials. Taylor counseled that feeding those denials into AI platforms can help generate an effective appeal letter. However, regardless of the steps taken or processes used, ongoing effort is essential when securing prior authorizations for rheumatology patients, according to Taylor. \u201cFighting back and continuing to put pressure on the insurance companies is advocacy work,\u201d she said. \u201cThese people making decisions on behalf of our patients don\u2019t know them. Continuing to push is advocacy in action.\u201d For more information: Katie Taylor, CMPM, CRH-c, CRMS, can be reached at kltaylor@signaturehealth.net. Published by: Sources\/Disclosures Source: Healio Interview Reference: Taylor K, Tsosie T. Prior Authorizations: Navigating Access and Advocacy. Presented at: Rheumatology Nurses Society annual conference; July 30 to Aug. 1, 2026, in Fort Lauderdale, Florida (hybrid meeting).
Disclosures:
Taylor reports no relevant financial disclosures.
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