Prior Authorization

By EMANUEL SARKEES

Most people have never heard of prior authorization until it personally stops them from getting care they actually need. The way it usually goes is pretty straightforward: a doctor sees a patient, figures out what is wrong, decides on a treatment, and writes the order. Then everything stops. Before anything can actually happen, the insurance company has to sign off. What makes this so frustrating is that it is not really one problem. It is a bunch of problems stacked on top of each other, where each one makes the next worse. Doctors lose hours, patients lose access, outcomes suffer, and the people who built the system are not the ones dealing with what it does to real patients.

Insurance companies say prior authorization is about preventing unnecessary care and keeping costs down. That argument has some logic to it on paper. But what the process actually looks like day to day has very little connection to that original idea. Doctors are drowning in paperwork, patients are waiting on treatments their physicians already approved, and outcomes are worse because of delays that did not have to happen. It was built to contain costs. What it is containing instead is care, and the patients on the receiving end had no say in how any of it was designed.

How It Works and Why It Doesn’t

A physician submits a request to an insurance company before prescribing a medication, ordering a procedure, or sending a patient to a specialist. The insurer looks at it and decides yes or no. That decision is supposed to come from a qualified medical professional who actually reviews the clinical picture. The data suggests that is not really what is happening.

The AMA’s 2025 physician survey found that the average doctor handles 40 prior authorization requests every week, eating up roughly 13 hours of their time. Almost two full working days every week are spent on paperwork instead of patients. Ninety-five percent of physicians surveyed said prior authorization gets in the way of necessary care. Seventy-nine percent said patients give up on treatment entirely because the process is too much or the approval never arrives.

What that produces is not an inconvenience. It is documented harm. A Johns Hopkins systematic review from September 2025 went through 25 studies and found prior authorization tied directly to disease progression, unnecessary hospitalizations, longer hospital stays, and lower survival rates in cancer patients. One in four physicians said a prior authorization delay had caused a serious adverse event for a patient, including permanent impairment or death. A RAND analysis from July 2025 pulled specific cases, including a kid with newly diagnosed Type 1 diabetes waiting in a hospital bed for approval on basic insulin, and an infant in respiratory distress turned away because a medication that was not even indicated had not been given first. These are not flukes. They are what happens when administrative decisions consistently override clinical ones with no real accountability in the process.

Who Gets Left Behind

Prior authorization does not land the same way for everyone. Low income patients and Medicaid patients face the highest denial rates and have the fewest realistic options when a denial comes through. Appealing takes time, paperwork, and persistence that is hard to maintain when you are working multiple jobs or dealing with a language barrier. For a lot of people the appeal never gets filed. The treatment gets dropped.

A 2025 KFF Health Tracking Poll found that 58% of insured adults who needed specialized care ran into a delay or denial because of prior authorization. For lower income patients that number is higher, and the consequences are more serious because there are not many alternatives when the answer is no. This fits a pattern that keeps showing up across American healthcare. People without insurance face it when they cannot afford to walk in the door. Low income patients face it when something is technically covered but impossible to access. Insured patients now face it when their doctor has already made the call and an insurance company decides differently. The wall keeps appearing in different places. It keeps stopping the same people.

The Promises Being Made

Some things have actually changed and it is worth acknowledging that.

In June 2025, around 60 health insurers committed to streamlining prior authorization, with changes rolling out through 2027. They pledged to reduce the number of services requiring authorization, standardize electronic submissions, and make sure clinical denials get reviewed by an actual licensed clinician.

In April 2026, CMS put out a proposed rule extending electronic prior authorization to prescription drugs, setting faster timelines for Medicare Advantage and Medicaid, and for the first time requiring insurers to publicly report approval and denial rates. That transparency piece matters. There has been suspicion for years that denial rates were high and timelines were being stretched. Now there will be numbers.

The issue is that only one in three physicians thinks the pledge will do much. That skepticism comes from experience. The insurance industry made almost the same pledge in 2018 and it changed almost nothing. The new CMS rule does not eliminate prior authorization, does not limit how many services can go through it, and does not touch commercial fully insured plans where most privately insured Americans actually sit. It also lets insurers pause decision timelines by requesting more information, which payer teams have already figured out how to use strategically. Eleven percent of prior authorizations have been cut since the June 2025 pledge. Eighty-nine percent of the burden remains.

What Needs to Actually Change

Pledges and better filing software are not going to get this done. Three structural changes would actually make a difference. First, gold carding needs to become a federal standard. Physicians with a strong track record of appropriate prescribing should be exempted from prior authorization for certain treatments. Arkansas, Texas, Colorado, and others have already done this, and it cuts administrative burden without increasing unnecessary care. Right now it is inconsistent and state dependent. A federal requirement fixes that.

Second, the CMS rule needs to cover commercial plans. Self-insured employer plans fall under ERISA and are largely outside CMS authority. That covers most working-age Americans. Leaving them out is not a minor gap.

Third, transparency needs consequences. When an insurer’s denial rates are consistently out of line with clinical standards, that should trigger regulatory review and real penalties, not just a published number that most patients will never find.

If none of this happens the direction is not hard to predict. Physician burnout keeps climbing, with prior authorization already one of the leading causes. Patients keep walking away from treatment when the paperwork gets to be too much. The people with the fewest options keep absorbing the most damage. And the costs of prior authorization are supposed to keep landing in emergency rooms and late stage diagnoses that end up costing the system far more than the denied approvals ever would have.

Prior authorization was supposed to make healthcare run better. What it built instead is a system where clinical judgment gets overruled by paperwork, where patients lose access because a form had an error or a deadline was missed, and where the people least able to fight back absorb the most damage. The insurance industry has responded by promising to do better. The doctors treating those patients are not convinced. Based on the track record, it is hard to say they are wrong.

Emanuel Sarkees is a high school student with a strong interest in medicine, healthcare, and innovations that improve patient care and access to treatment