From Red Tape to Relief: Rewriting the Rules of Prior Authorization

Insurers say the the prior authorization (PA) process stems from wanting to protect against overuse of care, unnecessary medical procedures, and incorrect care delivery, but critics say it has become more akin to a nightmare for any patient, provider, or payer thwarted by the roadblocks it continues to throw up.

“There is an element of prior authorization that, in theory, is necessary, is maybe even a safeguard. But over the past 5 to 10 years, it’s really just been viewed as a barrier, as an additional almost financial check or a way to introduce friction into the process so that a lot of times, patients or providers get frustrated and abandon the prescription, which is the exact opposite of what we want,” said Colin Banas, MD, MHA, chief medical officer at DrFirst, in a recent episode of Managed Care Cast, the podcast from The American Journal of Managed Care^®.¹ “In a perfect world, it’s supposed to be highly transparent, frictionless, seamless, easy to navigate and understand.”

A New Pledge for Reform

Six voluntary actions lie at the heart of a new pledge that more than 50 major health insurers have agreed to fulfill in an effort to overhaul and simplify the PA process, according to AHIP, the trade association that represents health insurance companies in the US, and the Blue Cross Blue Shield Association.²

A similar previous effort put forth in 2018 aimed to address 4 major pain points³:

• Increase transparency around requirements
• Expand PA capabilities
• Implement gold card programs for providers with high approval ratings
• Reduce requirements for routine services

This effort did not backfire, but it also did not lead to disruptive change. As recently as 2024, the American Medical Associated reported that 94% of physicians blame PAs for delays in care.

Not only are patients bogged down by this process, but health care providers and the overall system of health care as well, with much trust eroded due to excessive and what some view as unwarranted paperwork and delays in care. Industry collaboration is at the heart of this latest attempt to reform PAs, spearheaded by 3 primary guideposts: streamlining and accelerating approvals to prevent treatment delays; reducing red tape and cutting administrative waste, with potential savings in the billions; and using accountability to improve transparency through data.

These are the initial 6 reforms announced today. | Image Credit: CMS and HHS

Insurers that include Blue Cross Blue Shield in several states—Alabama, Hawaii, Louisiana, Nebraska, Rhode Island, and Tennessee, among others—Centene, Cigna, CVS Health Aetna, Highmark, Humana, Kaiser Permanente, SCAN Health, and UnitedHealthcare have committed to the following 6 reforms, to start:

• Ensuring care continuity following plan switches
• Enhancing communication and transparency on determinations
• Expanding real-time responses
• Guaranteeing medical review of nonapproved requests
• Reducing the scope of claims subject to PA
• Standardizing electronic PA

These initial commitments are slated to go live by January 2026, according to CMS Administrator, Mehmet Oz, MD, who spoke in a press conference today on this pledge to streamline the burdensome and aggravating PA process for the 75% of American lives covered by these initiatives. He was joined by HHS Secretary Robert F. Kennedy Jr; Senator Roger Marshall, MD (R, Kansas), a former obstetrician-gynecologist; Congressman Greg Murphy, MD (R, North Carolina); and actor Eric Dane.

The timeline is ambitious, with Oz noting the expectations are for real-time electronic decisions, continuity protection for patients switching plans, and expanded reforms for pharmacy and behavioral health to be de rigueur as soon as 2027—but that the government could intervene if these voluntary efforts fail.

Voices for Change

Following Oz, Dane and Marshall took the stage to underscore the human and systemic toll of the current PA process. Recently diagnosed with amyotrophic lateral sclerosis,⁴ or Lou Gehrig’s disease, Dane spoke candidly about the added burden of PAs during a health crisis. “When that diagnosis hits and you find out that you're sick, your life becomes filled with great uncertainty. The worst thing that we can do is add even more uncertainty for patients and their loved ones with unnecessary prior authorization,” he said, stressing the urgency of reform for all patients.

Marshall brought the provider’s perspective, calling PA the “number one bureaucratic nightmare” in health care, and sharing the story of a patient whose infertility surgery was abruptly canceled due to shifting insurance requirements—a scenario he likened to delays for hip replacements or cardiac care. “Physicians and nurses complain the process has become increasingly onerous because of constantly changing requirements, often demanding more time to navigate the red tape than to complete the presurgery medical workup today,” he said, by way of criticizing opaque rules that prioritize cost-cutting over care. Marshall pledged to continue pushing legislative reforms, aligning with CMS’ efforts to “prioritize patients over profits.”

Murphy, a practicing urologist, continued the string of criticisms, emphasizing how the drawn-out PA process even goes so far as to undermine the doctor-patient relationship, but also noting that physicians are not completely blameless in this regard. There are some, he explained, who prioritize profit over care and “game the system.” Is peer-to-peer review necessary then, he wondered, and should specialists evaluate denials, he asked, all the while expressing cautious optimism about the insurers’ reform pledges. Doctors must guide patient care, not the bureaucracy, the “opaque people in cubicles.” Accountability is key, he stressed.

There is a human cost to prior authorization, Kennedy echoed, and unfilled industry promises. Different this time, however, are the unprecedented scale, concrete standards, measurable deliverables, and deadlines infused throughout the proposed reforms. According to Kennedy, it was Harvard health economist David Cutler, PhD, who first spoke to “ending the scourge of preauthorization” early in President Donald Trump’s second term, with securing the voluntary commitments and convening the insurance CEOs falling to advisors Jake Levine and Chris Klump. These reforms, backed by decades-long advocacy, aim to eliminate the delays that burden providers and jeopardize patients, and he vowed rigorous oversight to ensure compliance.

References

1. Shaw M, Banas C. Stuck in prior auth purgatory: the hidden costs of health care delays. AJMC^®. June 19, 2025. Accessed June 23, 2025. https://www.ajmc.com/view/stuck-in-prior-auth-purgatory-the-hidden-costs-of-health-care-delays
2. Health plans take action to simplify prior authorization. News release. AHIP; June 23, 2025. Accessed June 23, 2025. https://www.ahip.org/news/press-releases/health-plans-take-action-to-simplify-prior-authorization
3. Health insurance industry is failing on prior authorization reform. Allzone Management Services, Inc. June 5, 2025. Accessed June 23, 2025. https://www.allzonems.com/health-insurance-industry-failing-on-prior-auth-reform/
4. Etienne V, Jordan J. Eric Dane announces he has been diagnosed with ALS (exclusive). People. April 10, 2025. Accessed June 23, 2025. https://people.com/eric-dane-diagnosed-with-als-exclusive-11713179