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 way in which it often goes is fairly easy: a physician sees a affected person, figures out what’s incorrect, decides on a remedy, and writes the order. Then the whole lot 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 drawback. It’s a bunch of issues stacked on prime of one another, the place each makes the following worse. Docs lose hours, sufferers lose entry, outcomes endure, and the individuals who constructed the system aren’t those coping with what it does to actual sufferers.
Insurance coverage firms 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 daily has little or no connection to that authentic thought. Docs are drowning in paperwork, sufferers are ready on remedies their physicians already accredited, and outcomes are worse due to delays that didn’t must occur. It was constructed to include 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 professional medical skilled who truly critiques the medical 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 p.c of physicians surveyed stated prior authorization will get in the way in which of vital care. Seventy-nine p.c stated sufferers surrender on remedy solely as a result of the method is an excessive amount of or the approval by no means arrives.
What that produces isn’t an inconvenience. It’s documented hurt. A Johns Hopkins systematic review from September 2025 went via 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 precipitated a severe adversarial occasion for a affected person, together with everlasting impairment or loss of life. A RAND analysis from July 2025 pulled particular circumstances, together with a child with newly recognized Kind 1 diabetes ready in a hospital mattress for approval on fundamental 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 constantly override medical ones with no actual accountability within the course of.
Who Will get Left Behind
Prior authorization doesn’t land the identical manner for everybody. Low revenue sufferers and Medicaid sufferers face the best denial charges and have the fewest real looking choices when a denial comes via. Interesting takes time, paperwork, and persistence that’s exhausting to keep up 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 larger, and the implications are extra severe as a result of there aren’t many alternate options when the reply is not any. This matches a sample that retains displaying up throughout American healthcare. Individuals with out insurance coverage face it once they can not afford to stroll within the door. Low revenue sufferers face it when one thing is technically lined however unimaginable to entry. Insured sufferers now face it when their physician has already made the decision and an insurance coverage firm decides in another way. The wall retains showing elsewhere. It retains stopping the identical folks.
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 via 2027. They pledged to scale back the variety of providers requiring authorization, standardize digital submissions, and ensure medical 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 sooner 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 can be numbers.
The problem is that only one in three physicians thinks the pledge will do much. That skepticism comes from expertise. The insurance coverage business made virtually the identical pledge in 2018 and it modified virtually nothing. The brand new CMS rule doesn’t remove prior authorization, doesn’t restrict what number of providers can undergo it, and doesn’t contact business totally insured plans the place most privately insured Individuals truly sit. It additionally lets insurers pause choice timelines by requesting extra data, which payer groups have already discovered use strategically. Eleven p.c of prior authorizations have been reduce for the reason that June 2025 pledge. Eighty-nine p.c of the burden stays.
What Must Really Change
Pledges and higher submitting software program aren’t going to get this executed. Three structural adjustments would truly make a distinction. First, gold carding must grow to be a federal customary. Physicians with a robust monitor document of acceptable prescribing needs to be exempted from prior authorization for sure remedies. Arkansas, Texas, Colorado, and others have already executed 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 business plans. Self-insured employer plans fall below ERISA and are largely exterior CMS authority. That covers most working-age Individuals. Leaving them out isn’t a minor hole.
Third, transparency wants penalties. When an insurer’s denial charges are constantly out of line with medical requirements, that ought to set off regulatory assessment and actual penalties, not only a printed quantity that the majority sufferers won’t ever discover.
If none of this occurs the route isn’t exhausting to foretell. Physician burnout keeps climbing, with prior authorization already one of many main causes. Sufferers preserve strolling away from remedy when the paperwork will get to be an excessive amount of. The folks with the fewest choices preserve absorbing probably 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 way over 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 medical judgment will get overruled by paperwork, the place sufferers lose entry as a result of a kind had an error or a deadline was missed, and the place the folks least in a position to combat again take up probably 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 monitor document, it’s exhausting to say they’re incorrect.
Emanuel Sarkees is a highschool scholar with a robust curiosity in medication, healthcare, and improvements that enhance affected person care and entry to remedy
