Start a Prior Authorization Service for Medical Practices

1. 1

   Pick a specialty and learn its auth patterns

   Prior auth is specialty-specific: advanced imaging, orthopedic procedures, dermatology biologics, and specialty medications each have their own payer criteria and portals. Deep knowledge of one specialty's patterns beats shallow coverage of all of them, and it is how you promise realistic turnarounds.

2. 2

   Map the payer landscape you will work

   Each major payer has portals, forms, clinical criteria documents, and peer-to-peer escalation paths. Build a cheat sheet per payer: where to submit, what clinical documentation each service needs, and typical decision windows.

3. 3

   Set up compliant remote operations

   You will access practice systems and patient records remotely, so you need business associate agreements, encrypted everything, and defined access procedures. Many practices will set you up inside their EHR and payer portals as an authorized user.

4. 4

   Price per authorization with volume tiers

   Per-auth pricing (tiered by complexity: medication refill renewals versus surgical authorizations with clinical documentation assembly) is easy to compare against staff time. Offer monthly bundles per provider once volume is proven.

5. 5

   Promise tracking, not miracles

   You cannot guarantee approvals; you can guarantee same-day submission, complete documentation, relentless status checks, and immediate escalation of denials to peer-to-peer review. Practices buy the reliability, and reliability is entirely in your control.

6. 6

   Watch the electronic prior auth shift

   CMS rules require major payers to stand up electronic prior authorization APIs by 2027, which will change workflows but not eliminate the judgment work of assembling clinical justification. Position yourself as the operator who rides the tooling shift, and consider partnering with automation platforms as they mature.

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Best for: Medical assistants, pharmacy techs, and office staff who already know the payer maze

Not for: This is not for people with zero medical office experience or anyone who needs to control outcomes to feel successful; payers deny things, and your value is disciplined process, not magic. If following up daily on 40 pending requests sounds unbearable, pick another lane.