Prior Authorization: A Harmful and Insulting Barrier to Accessing Care in America

Prior authorization (PA) began with a seemingly logical premise: let’s have doctors request upfront approval before the insurance company pays for the healthcare services prescribed. But as physicians, we all know that PA is deeply flawed: It fundamentally alters the practice of medicine. It reduces physician autonomy, it adds to our already overwhelming administrative workload, and it leads to significant emotional and financial stress for patients. All of these can lead to negative outcomes for patients. While insurers wrap prior authorization in rhetoric about "quality of care" and "patient safety," its implementation often actively undermines these very goals.

Consider these scenarios which I've witnessed through colleagues:

A patient with aggressive cancer, prescribed a targeted therapy based on their specific tumor genetics, forced to try and fail multiple older treatments before accessing the recommended medication. Each week of delay represents not just lost time, but lost opportunity for effective intervention.

An epilepsy patient, finally stable on a medication regimen carefully calibrated by their neurologist, suddenly forced to switch to an alternative by their insurer. The resulting breakthrough seizures don't appear in any insurance company metrics, but they fundamentally disrupt a life previously brought under control (and waste money that the insurer is ironically trying to save!)

There are countless similar situations which underscore how PA has strayed from its original purpose and created a bureaucratic labyrinth that delays care, increases costs, and fundamentally damages the doctor-patient relationship. (Need more proof? Here’s over 100 replies from physicians on Bluesky when I asked the question.)

As physicians, we have the power to reform this broken system – look no further than a new bill that physicians like Dr. Tina Shah helped to enact in New Jersey that goes into effect this week. But in order to do so, we must understand the history of PA and the current technological and clinical trends shaping PA today.

Prior Authorization: A Historical Conext

Prior authorization emerged in the 1980s and 1990s. It targeted expensive, discretionary procedures like elective surgeries and advanced imaging, and aimed to prevent unnecessary interventions and protect patients from potential harm. The original intent wasn't entirely misguided — after all, not every child in the 1950s needed their tonsils removed, though physicians were happy to perform these profitable procedures. Early PA tried to rely on solid evidence to ensure appropriate care while avoiding overutilization. For example, “Maybe the patient who threw his back out but is now doing better doesn’t need an immediate MRI.”

However, this system changed over time. Entities who had decision-making authority also had:

• Financial incentives to deny care
• No direct knowledge of the patient’s condition
• No legal liability for negative outcomes

While physicians are ethically and legally bound to prioritize patient welfare, insurance companies and their reviewers operate under a fundamentally different set of incentives.

The Mechanics of Prior Authorization

As physicians, you probably know how the PA process works. But in case you’re early in your medical career, here’s a primer:

• The doctor sees the patient and wants to do a particular test. (Note: Since many doctors are now employees of health systems, they have no personal financial incentive to pick an overly expensive drug or test.)
• The doctor submits a bunch of paperwork about why the patient needs this [intervention].
• The insurer reviews the request, often initially reviewed by people with minimal medical training (or with automated AI tools).
• There’s sometimes more back-and-forth, requesting additional documentation spanning days to weeks.
• Then the insurer responds with an approval, denial, or modification.
• The doctor and/or patient can then appeal, which requires even more documentation, time on the phone with a “peer” (supposed to be a doctor employed by the health insurer which doesn’t always happen), and can require additional days or weeks.

The doctor is not paid for this time. He or she often has to employ medical staff just to handle prior auth requests. And the patient waits in limbo for days, weeks, or months for a treatment their doctor has told them is necessary for their health.

How the Expansion of Prior Authorization Benefits Insurance Companies

Prior authorization has evolved into an all-encompassing mechanism, far removed from its original intent. This transformation was driven by three main factors:

• Escalating Healthcare Costs: Rising expenditures prompted insurers to expand PA as a primary cost-control strategy.
• Advances in Medical Technology: Each new diagnostic tool, procedure, or pharmaceutical innovation brought higher costs, leading insurers to apply prior authorization to common areas of medicine instead of just rare ones.
• Potential Further Profit Opportunity: Prior authorization slows down medical care. Could insurers make the prior authorization process simple, or transparent, or intuitive or fair? Of course they could. They’ve chosen not to, and I believe this is at least partially because of their responsibility to their shareholders, not to their patients. Even JAMA referred to prior auth as “a game.”

Statistics Reveal the Magnitude of PA's Expansion

• Medicare Advantage: Requests increased from 37 million in 2019 to over 46 million in 2022, with enrollment predicted to eventually reach 75% of Medicare beneficiaries.
• Private Insurance: A 2023 AMA survey found 56% of physicians reporting increased PA requirements, and 87% reporting that PA actually increased utilization of healthcare resources.
• State Medicaid: A 2022 HHS analysis revealed millions of improper denials by Medicare Advantage plans, often for services that traditional Medicare would have covered.

Perhaps most troubling is how prior authorization exploits a fundamental asymmetry in healthcare delivery:

• Insurers bear minimal liability for delayed or denied care
• Physicians retain full legal responsibility for patient outcomes
• Patients suffer the consequences while having the least power in the system

PA’s Negative Impact on Physicians and Medical Practice

Physicians must think twice before ordering tests or treatments as they’re now put between a rock and a hard place: ordering the intervention forces them to do additional unpaid work in order to advocate for their patient. Not ordering the intervention breaks our ethical code to put patients’ needs always above our own.

PA steals time from patient care. The numbers are staggering: physicians spend an average of 14 hours per week wrestling with prior authorization requirements. That's nearly two full workdays not spent on direct patient care. Many practices now employ full-time staff solely to handle these requirements. We also know that physicians must navigate PA even for standard, evidence-based therapies, like generic nausea medicines for patients undergoing chemotherapy (Zofran).

What once might have been a concise, clinically focused note has become a bureaucratic exercise in anticipating insurance company demands. We're no longer just documenting for clinical care — we're writing to satisfy non-medical reviewers who may not understand something as routine as "carcinoma" meaning cancer.

PA erodes physician autonomy. The prior authorization system fundamentally challenges physician autonomy and the doctor-patient relationship. And the psychological impact on physicians cannot be overstated. We took an oath to put patients first, yet increasingly find ourselves unable to fulfill that promise without first seeking permission from insurance company algorithms. Prior authorization applied broadly assumes that the doctor is “guilty of poor medical judgment” until being proven “innocent” by the insurer. We are also the face of the healthcare system, and are ultimately the one that will be blamed for delays and denials.

The Patient Experience: Why PA Fails Our Patients

While insurers frame PA as a quality control measure, the lived reality for patients often reveals a system that creates barriers to care rather than protections.

The statistics are striking: 93% of providers report that their patients experience treatment delays due to prior authorization. Oncologists report similar numbers with 80% reporting cancer progressing due to delays and 36% reporting deaths due to PA delays. Behind each percentage point lies a story of suffering, anxiety, and eroded trust in the healthcare system.

The ripple effects also extend far beyond immediate care delays:

• Psychological Impact: Patients face profound anxiety navigating a system that seems designed to obstruct rather than facilitate care. The uncertainty of approval, combined with the stress of potentially being denied necessary treatment, adds an additional layer of suffering to already challenging medical conditions. We know that 78% of doctors report PA causing some patients to abandon treatment altogether.
• Financial Toxicity: Even when treatments are eventually approved, the delays often force impossible choices. “Do I try to pay out of pocket for these needed medications or wait through a lengthy appeals process?” This creates a particularly cruel dilemma for those already struggling with the costs of chronic illness.
• Health Inequity: The burden falls heaviest on those least equipped to navigate complex bureaucratic systems. Patients from marginalized communities, those with limited English proficiency, or individuals lacking technological literacy face compounded barriers in an already challenging process.

To Understand Who Benefits from PA, Follow the Money

Even if insurance executives proclaim that prior authorization is not intended to make them money, it is impossible to deny that it does. Here’s how:

Direct Cost Avoidance: Beyond simple denial of services, the mere existence of PA requirements creates a deterrent effect. Physicians, knowing the burden of the authorization process, may hesitate to prescribe certain treatments—even when clinically appropriate. A 2021 study in Health Affairs estimated that prior authorization from insurers costs everyone else in the healthcare system $90B a year.

The Power of Delay: Even when insurers ultimately approve procedures, delays in authorization translate directly to financial gains. Every week of delayed payment represents additional time that premium dollars can generate investment returns for insurance companies.

Algorithmic Efficiency: The rise of AI-driven denial systems has made it increasingly cost-effective for insurers to implement broad PA requirements. The human cost of these automated decisions remains largely unexamined, but ProPublica’s reporting on UnitedHealthcare’s AI tools is quite damning. STAT News also reported on an AI tool that auto-denied 90% of claims for UHC, and NY Mag also has a very nice overview of prior authorization.

PA Reform Efforts: Signs of Change

After years of mounting frustration, we're finally seeing meaningful pushes for reform. Perhaps most promising are state-level reforms, where laboratories of democracy are experimenting with different approaches to taming the prior authorization beast. These efforts reflect a growing recognition that the status quo has become untenable for both patients and providers.

Take New Jersey's bold new law, effective January 1:

• 24-hour response requirements for urgent cases
• 72-hour maximum for standard requests
• Auto-approval if deadlines aren't met
• Required reviewer credentials including recent state practice experience
• Mandatory transparency in PA criteria and denial statistics

This represents a fundamental shift in approach—rather than accepting insurer delays as inevitable, it treats time as a precious clinical resource.

Texas has taken a different but equally innovative path with its "gold card" system. By exempting high-performing providers from routine PA requirements, it acknowledges what we've long known: the vast majority of physician requests are ultimately approved once appealed (if they have the time and energy to fight the denial). This approach rewards clinical expertise while preserving resources for cases that truly warrant review.

Other states have attempted smaller prior authorization reform, for example Colorado has changed PA requirements for some medications and Oklahoma has proposed mandating the publication of prior authorization standards on insurer websites for transparency, while New York has banned prior authorization for the first 14 days of mental health hospitalizations. There’s a great PA state-level tracker from the ACP available as well.

There Is a Federal Evolution Underway for Prior Authorization

While Congress remains gridlocked on many healthcare issues, even here we are beginning to see signs of movement. The Improving Seniors' Timely Access to Care Act, despite its current holding pattern in the House, represents a bipartisan acknowledgment of PA's systemic failures.

More concretely, CMS's Interoperability and Prior Authorization Final Rule signals a shift in regulatory thinking. Though its implementation timeline stretches years into the future, its requirements for electronic processes and transparent denial reasoning suggest a recognition that the current system's opacity serves no one but insurers.

The Promise and Peril of AI for Prior Authorization

The emergence of AI in this space presents a fascinating dichotomy. While startups promise to streamline authorization processes, there are clear potential pitfalls. I can't help but imagine a future where AI authorization bots engage in endless loops with AI denial algorithms, creating a high-tech version of our current gridlock, and I’m not alone.

Yet innovative approaches are emerging. Mark Cuban's initiative to eliminate PA requirements for his companies' self-insured plans represents a radical rethinking of the employer-insurer relationship. By trusting physician judgment while using analytics to identify true outliers, this model might chart a path toward more efficient, trust-based systems.

And don’t count out the EHRs; this year at UGM, Epic’s Judy Faulkner announced new tools with payor partners to streamline the PA system as well.

A Call for Systemic Transformation

While recent reform efforts offer hope, they also highlight the scale of change needed.

If you look at any chart of American healthcare spending, more prior authorization has not slowed healthcare spending. By contrast, numerous other countries have far more effective strategies to contain costs: Taiwan has global budgets, Japan uses a fee schedule, the UK’s NICE performs cost-effectiveness reviews, and Germany does price negotiation. But in America, we have uniquely adopted the least effective option that incurs the biggest costs to our patients physical, mental, and financial well-being.

Here are two other options that I think might solve the prior authorization pain:

• Hold insurers medico-legally responsible for bad outcomes that occur due to prior authorization delays, denials, and run-arounds.
• Allow physicians to bill insurers by the minute for the time required to handle prior authorizations. “You want me to spend 30 minutes on the phone arguing about generic nausea medicine that costs you $3 for cancer patients getting chemo? Okay great, that’ll be $400.”

For those of us on the front lines of medicine, the path forward is clear: We must continue advocating for our patients while working toward systemic reforms that restore clinical judgment to its proper place.

We must also restore trust in physician judgment. While oversight has its place, the current system's presumption of physician error unless proven otherwise fundamentally misaligns incentives and undermines care. (And physicians and health systems must hold up their end of the bargain as well.)

As we push for change, let's remember what brought us to medicine in the first place— the desire to heal, to comfort, and to serve. Prior authorization too often stands between us and these fundamental duties. It's time for a system that supports rather than impedes these essential goals.

The cost of inaction is paid daily in patient suffering, physician burnout, and wasteful bureaucracy. We can — and must — do better.