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Jul 3, 2025
Prior Authorization Reform: Time for Action
WASHINGTON, D.C., July 3, 2025
Promises, Promises? Health Insurers Vow Prior Authorization Fixes Again
Will this time be different, or just another round of hollow commitments?
- Major health insurers have pledged to reform prior authorization processes.
- Similar pledges in 2018 and 2023 yielded limited positive results.
- Physicians report increasing prior authorization requests and denials.
- The AMA is pushing for standardization and legislative solutions.
The commitment by major health insurers to reform prior authorization is welcome news, but **will these reforms to prior authorization** truly materialize into meaningful change for physicians and patients?
Been there, heard that? In 2018 and again in 2023, big health insurers promised a structural overhaul of prior authorization to ensure safe, timely, and affordable access to evidence-based care, while easing the administrative burden on doctors and improving transparency.
Elements of this latest pledge echo those made seven years ago, including reducing the number and scope of claims requiring prior authorization, automating the process for faster responses and greater transparency, and protecting continuity of care.
Progress Slow to Materialize
It’s fair to ask if the results of prior efforts have been underwhelming. A recent survey found that over 80% of physicians reported an increase in prior authorization requests for both medical services and prescription medications over the past five years.
A staggering 75% of physicians reported increased denials during that same period. Even more concerning, over three-fourths of physicians said prior authorization led patients to abandon treatment, and nearly one-fifth reported a patient requiring hospitalization as a result.
Did you know? Antiquated technology, such as fax machines, are still commonly used by health insurers, further delaying patient care.
Automation aimed at improving transparency and efficiency has also lagged, and phone calls remain the most common method for completing prior authorization requests, as national standards for electronic transactions have yet to be widely adopted. The average practice handles about 40 prior authorization requests weekly, and nearly half have staff solely dedicated to this function.
Right-Sizing Prior Authorization
The goal is to streamline and simplify a process that has evolved from a rarely used tool for limiting expensive, new medications into a standard utilization management strategy applied even to simple generic medications and time-tested treatments.
Just a few months ago, a staff member had to call an insurer because a physician’s name wasn’t appearing as a provider in their system, despite a quarter-century of practice in Michigan. It’s a symptom of an unsustainable process needing change.
To fully grasp the extent of the problem and the reforms needed, other physicians share some of their very worst experiences with prior authorization.
Advocating for Real Solutions
The effort outlined in late June by Mehmet Oz, MD, Administrator of the Centers for Medicare & Medicaid Services, aims to improve this situation.
The nation’s leading health insurers agreed to six key reforms:
- Standardizing electronic prior authorization requests.
- Reducing the number and scope of these requests.
- Ensuring care continuity when patients change health plans.
- Explaining denials and provide instructions for appeals.
- Speeding approval response times for patients and providers.
- Ensuring all denials based on medical necessity continue to be reviewed by a licensed and qualified clinician.
These commitments could reshape prior authorization, improve patient outcomes, and allow physicians to focus on direct patient care.
For example, insurers pledging to standardize electronic requests could mean one application icon on computer screens launching a single prior authorization program for all health plans. Instead of numerous apps for different insurers, physicians could click one icon to send information to any payer.
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</div>Standardization could also apply to the questions physicians answer for authorization. Currently, different insurers ask different questions for the same tests or procedures, despite the underlying medical science remaining constant.
Careful monitoring of the implementation of these reforms is expected to help ensure good intentions translate into reality. Insurers should do more than give lip service to prior authorization reform.
Efforts to reform prior authorization continue and close work with federal and state policymakers on legislative and regulatory solutions such as gold carding programs are in the plan which allow physicians who routinely have their requests approved for certain medications and procedures to skip prior authorization for those treatments. Strong support exists for legislation pending in Congress, the Improving Seniors’ Timely Access to Care Act which would codify prior authorization reforms with bipartisan backing.
Cautious optimism surrounds the current pledge to curb overzealous prior authorization, with a commitment to cooperate with health plans to protect and benefit patients.
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