Prior Authorization Reform Must Go Beyond Faster Decisions

Access to healthcare depends on more than whether an effective treatment exists or whether a patient has insurance. It also depends on whether patients can receive that care in time and whether doctors and hospitals can deliver it without being overwhelmed by administrative barriers. When the system delays treatment while adding staff time and expense, patients can become sicker, and the ultimate cost of their care can increase.

That is why efforts to reform prior authorization are so important. Although this utilization-management tool can serve a legitimate role in discouraging unnecessary or inappropriate care, it has also become a frequent source of delays for patients and administrative burdens for providers. Fortunately, reform efforts are finally moving in the right direction after years of frustration. 

Federal regulators and insurers have begun eliminating unnecessary reviews and bringing greater transparency to a system still reliant on fragmented portals and analog information exchanges. Participating insurers report eliminating 11% of prior authorization requirements since joining a voluntary industry pledge to streamline the system in June 2025. That represents an estimated 6.5 million fewer requests. The Centers for Medicare and Medicaid Services has also shortened certain decision deadlines and required covered insurers to explain denials. Plans must now make data about their authorization outcomes and response times publicly available.

These changes represent meaningful progress, but they should be treated as the beginning of reform rather than evidence that the problem has been solved. The information emerging from the new transparency requirements has also exposed an unresolved problem: reforms focused heavily on reducing the number of reviews and accelerating responses do not ensure that the decisions insurers make are accurate or clinically justified.

In fact, a new analysis of data reported by large insurers found that the denial rate approached one in five standard prior authorization requests in the federal Affordable Care Act Marketplace during 2025. In Medicare Advantage, meanwhile, insurers later reversed more than two-thirds of the denials that patients or providers appealed. Some appeals may include information that was not part of the original request, but reversal rates this high still raise serious concerns about the quality of initial reviews. A faster answer provides little comfort if patients and providers must then spend days or weeks correcting that decision.

For patients, these delays are more than just an administrative inconvenience. A review led by Johns Hopkins researchers found that prior authorization requirements were associated with delays that allowed some patients’ conditions to worsen. In some cases, those delays even contributed to preventable hospitalizations or kept patients hospitalized longer. Ironically, a tool intended to control costs can increase them when a manageable health problem becomes more serious, leaving patients to suffer the consequences.

The impact also ripples through hospitals and provider organizations. Clinicians lose time that could be spent treating patients, as more staff time must be dedicated to preparing insurer documentation and pursuing appeals. CMS estimates that requesting prior authorizations consumes approximately 700 hours and $34,000 in administrative expenses annually for each healthcare provider. Rural and safety-net hospitals, many with limited administrative capacity and little financial flexibility, are particularly poorly positioned to absorb these costs.

To address these continuing problems, policymakers should focus on reducing how often prior authorization is required while improving the decision-making process for the reviews that remain. Insurers should remove requirements from services they routinely approve. Providers with strong approval records should be exempted from repetitive reviews, and routine requests should qualify for real-time electronic decisions. Existing authorizations should also follow patients who change plans, so they are not forced to restart the process.

Modernization must also come with safeguards. Automated tools can speed routine decisions, but they should not independently determine whether medically necessary care is denied. The Medicaid and CHIP Payment and Access Commission recently found limited transparency into how these systems make decisions and uneven oversight of their use. Any denial based on medical necessity should therefore receive individualized review by an appropriately qualified clinician.

Most importantly, accountability must extend beyond aggregate denial rates. Insurers should disclose which categories of care they deny most often and how frequently those decisions are reversed. They should also explain the role automated tools played. Plans with unusually high denial or reversal rates should face audits and corrective action. Ultimately, patients and providers should have an appeals system that is easier to navigate when a decision is challenged.

Prior authorization reform has begun reducing unnecessary reviews and bringing previously hidden problems into view. Policymakers should now build on that progress by making sure a system intended to manage healthcare costs does not shift greater clinical and financial burdens onto patients and the hospitals that their communities depend upon.

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