By EMANUEL SARKEES
Most individuals have by no means heard of prior authorization till it personally stops them from getting care they really want. The best way it normally goes is fairly easy: a health care provider sees a affected person, figures out what’s flawed, decides on a remedy, and writes the order. Then every little thing stops. Earlier than something can truly occur, the insurance coverage firm has to log out. What makes this so irritating is that it’s not actually one downside. It’s a bunch of issues stacked on high of one another, the place every one makes the subsequent worse. Medical doctors lose hours, sufferers lose entry, outcomes undergo, and the individuals who constructed the system aren’t those coping with what it does to actual sufferers.
Insurance coverage corporations say prior authorization is about stopping pointless care and maintaining prices down. That argument has some logic to it on paper. However what the method truly seems like everyday has little or no connection to that unique thought. Medical doctors are drowning in paperwork, sufferers are ready on therapies their physicians already authorized, and outcomes are worse due to delays that didn’t should occur. It was constructed to comprise prices. What it’s containing as a substitute is care, and the sufferers on the receiving finish had no say in how any of it was designed.
How It Works and Why It Doesn’t
A doctor submits a request to an insurance coverage firm earlier than prescribing a medicine, ordering a process, or sending a affected person to a specialist. The insurer seems at it and decides sure or no. That call is meant to return from a certified medical skilled who truly opinions the scientific image. The information suggests that’s not actually what is occurring.
The AMA’s 2025 physician survey discovered that the typical physician handles 40 prior authorization requests each week, consuming up roughly 13 hours of their time. Nearly two full working days each week are spent on paperwork as a substitute of sufferers. Ninety-five % of physicians surveyed stated prior authorization will get in the best way of vital care. Seventy-nine % stated sufferers hand over on remedy fully as a result of the method is an excessive amount of or the approval by no means arrives.
What that produces shouldn’t be an inconvenience. It’s documented hurt. A Johns Hopkins systematic review from September 2025 went by 25 research and located prior authorization tied on to illness development, pointless hospitalizations, longer hospital stays, and decrease survival charges in most cancers sufferers. One in 4 physicians stated a previous authorization delay had brought about a critical hostile occasion for a affected person, together with everlasting impairment or demise. A RAND analysis from July 2025 pulled particular circumstances, together with a child with newly identified Kind 1 diabetes ready in a hospital mattress for approval on primary insulin, and an toddler in respiratory misery turned away as a result of a medicine that was not even indicated had not been given first. These aren’t flukes. They’re what occurs when administrative choices persistently override scientific ones with no actual accountability within the course of.
Who Will get Left Behind
Prior authorization doesn’t land the identical means for everybody. Low revenue sufferers and Medicaid sufferers face the best denial charges and have the fewest life like choices when a denial comes by. Interesting takes time, paperwork, and persistence that’s onerous to take care of when you find yourself working a number of jobs or coping with a language barrier. For lots of people the attraction by no means will get filed. The remedy will get dropped.
A 2025 KFF Health Tracking Poll discovered that 58% of insured adults who wanted specialised care ran right into a delay or denial due to prior authorization. For decrease revenue sufferers that quantity is greater, and the results are extra critical as a result of there aren’t many options when the reply isn’t any. This matches a sample that retains exhibiting up throughout American healthcare. Individuals with out insurance coverage face it after they can’t afford to stroll within the door. Low revenue sufferers face it when one thing is technically lined however unattainable to entry. Insured sufferers now face it when their physician has already made the decision and an insurance coverage firm decides otherwise. The wall retains showing elsewhere. It retains stopping the identical individuals.
The Guarantees Being Made
Some issues have truly modified and it’s value acknowledging that.
In June 2025, round 60 well being insurers dedicated to streamlining prior authorization, with adjustments rolling out by 2027. They pledged to cut back the variety of companies requiring authorization, standardize digital submissions, and ensure scientific denials get reviewed by an precise licensed clinician.
In April 2026, CMS put out a proposed rule extending digital prior authorization to prescribed drugs, setting quicker timelines for Medicare Benefit and Medicaid, and for the primary time requiring insurers to publicly report approval and denial charges. That transparency piece issues. There was suspicion for years that denial charges have been excessive and timelines have been being stretched. Now there might be numbers.
The difficulty is that only one in three physicians thinks the pledge will do much. That skepticism comes from expertise. The insurance coverage business made nearly the identical pledge in 2018 and it modified nearly nothing. The brand new CMS rule doesn’t get rid of prior authorization, doesn’t restrict what number of companies can undergo it, and doesn’t contact industrial totally insured plans the place most privately insured People truly sit. It additionally lets insurers pause choice timelines by requesting extra data, which payer groups have already discovered how you can use strategically. Eleven % of prior authorizations have been reduce because the June 2025 pledge. Eighty-nine % of the burden stays.
What Must Really Change
Pledges and higher submitting software program aren’t going to get this achieved. Three structural adjustments would truly make a distinction. First, gold carding must change into a federal commonplace. Physicians with a robust observe document of acceptable prescribing must be exempted from prior authorization for sure therapies. Arkansas, Texas, Colorado, and others have already achieved this, and it cuts administrative burden with out rising pointless care. Proper now it’s inconsistent and state dependent. A federal requirement fixes that.
Second, the CMS rule must cowl industrial plans. Self-insured employer plans fall beneath ERISA and are largely exterior CMS authority. That covers most working-age People. Leaving them out shouldn’t be a minor hole.
Third, transparency wants penalties. When an insurer’s denial charges are persistently out of line with scientific requirements, that ought to set off regulatory evaluate and actual penalties, not only a revealed quantity that the majority sufferers won’t ever discover.
If none of this occurs the path shouldn’t be onerous to foretell. Physician burnout keeps climbing, with prior authorization already one of many main causes. Sufferers hold strolling away from remedy when the paperwork will get to be an excessive amount of. The individuals with the fewest choices hold absorbing essentially the most injury. And the prices of prior authorization are supposed to maintain touchdown in emergency rooms and late stage diagnoses that find yourself costing the system excess of the denied approvals ever would have.
Prior authorization was imagined to make healthcare run higher. What it constructed as a substitute is a system the place scientific judgment will get overruled by paperwork, the place sufferers lose entry as a result of a type had an error or a deadline was missed, and the place the individuals least capable of battle again take up essentially the most injury. The insurance coverage business has responded by promising to do higher. The docs treating these sufferers aren’t satisfied. Based mostly on the observe document, it’s onerous to say they’re flawed.
Emanuel Sarkees is a highschool pupil with a robust curiosity in drugs, healthcare, and improvements that enhance affected person care and entry to remedy
