“If I had a dollar for every hour lost to prior authorizations, I’d retire yesterday.” — A frustrated primary care physician’s hot take on a problem we all face.
If you’re a medical provider, you know this pain all
too well. Prior authorizations (PAs) are meant to ensure appropriate care
and control costs. But what they’ve become is a massive administrative
burden stealing precious time away from patients — and frankly, from life
outside the clinic.
This week, with fresh legislative proposals and industry
shifts making headlines, it’s the perfect moment to talk about prior
authorization reform, why it matters, and how we can actually make it
better.
Let’s dive into real stories, expert insights, and
actionable tips that can help you navigate the PA maze — and maybe even push
for change.
The Story: When Paperwork Costs Lives
Dr. Amy Hernandez, a family physician in Texas, recalls a
recent case that made her rethink everything about prior authorization:
“A patient with severe asthma needed a biologic that could
be a game-changer. The PA process took three weeks. Three weeks! Meanwhile, the
patient was in the ER twice. That delay was dangerous — and unacceptable.”
This is not an isolated story. Across the country, providers
spend up to 14 hours a week on prior authorization paperwork — time that
could be spent diagnosing, treating, or just catching a breath.
And patients? They face treatment delays,
frustration, and sometimes worse outcomes. Something has to change.
Why Does Prior Authorization Feel Like a Brick Wall?
Before we get into solutions, here’s a quick reality check
on why PAs are so tough:
- Complexity
& Variability: Each insurer has different rules, forms, and
criteria.
- Lack
of Transparency: Providers often don’t know why requests are denied or
delayed.
- Time-Consuming
Processes: Manual faxing, phone calls, and resubmissions.
- Inconsistent
Criteria: What’s approved in one region may be denied in another.
- Pressure
on Providers: Physicians and staff spend hours that add up to burnout.
In 2025, the administrative cost burden of prior
authorization is estimated at $31 billion annually nationwide. That's
billions of dollars lost to inefficient processes that don’t directly improve
patient care.
Expert Opinions: What Are Medical Leaders Saying?
We reached out to three medical experts currently working on
PA reform and healthcare administration to get their take.
Dr. Lisa Matthews, MD, Health Policy Analyst
"Prior authorization was designed to safeguard
patients, but the process has grown outdated. Technology and standardized
criteria can and should make approvals automatic in many cases. The current
chaos is a failure of coordination, not necessity."
Michael Stevens, MPH, Healthcare Operations Consultant
"Providers are drowning in paperwork. Reform must
focus on automation, transparency, and accountability. We need real-time
electronic PA systems that talk directly to EHRs, not manual, redundant
workflows."
Dr. Rajesh Kumar, MD, Primary Care Physician and Advocate
"Patients suffer when access is delayed. I advocate
for eliminating PA for chronic condition meds where guidelines are clear. The
system punishes doctors trying to do the right thing."
Top 7 Tips to Navigate Prior Authorization Today
- Build
a PA Toolkit
Keep templates, checklist forms, and denial appeal letters handy. It saves precious time. - Assign
a Dedicated Staff Member
If possible, delegate PA management to a trained team member who can track and follow up efficiently. - Use
Electronic PA Systems
Many insurers now offer portals integrated with EHRs. Push your practice to adopt these to cut down manual effort. - Document
Everything Clearly
Clear documentation of medical necessity upfront reduces back-and-forth. - Stay
Updated on Insurer Policies
Rules change frequently. Subscribing to insurer newsletters or updates can keep you ahead. - Appeal
Denials Quickly
Don’t wait. Many approvals happen during the appeal phase. - Engage
Patients in the Process
Educate your patients about potential delays and empower them to call insurers when needed.
Tactical Advice for Healthcare Leaders and Practices
- Pilot
Automation Tools: Invest in PA automation platforms that integrate
with your existing EHR. Measure time saved and patient outcomes improved.
- Advocate
at a Policy Level: Join or support organizations pushing for PA
reform, such as the American Medical Association’s “Prior Authorization
Reform” initiative.
- Train
Your Team Regularly: PA processes change rapidly. Regular training
keeps everyone sharp and reduces errors.
- Collect
Data on PA Delays: Track delays, denials, and impact on care. Use this
data to support appeals and advocate for system improvements.
- Explore
Delegated Prior Authorization: Some payers allow trained staff to
manage routine PAs with less physician input. Investigate this option.
Open Failures: What’s Not Working?
It’s important to be honest. Many reforms have been proposed
but failed due to:
- Fragmented
Insurance Industry: No universal standards across payers.
- Resistance
to Change: Insurers fear losing control or increased costs.
- Technology
Gaps: Many practices lack funds for costly tech upgrades.
- Short-Term
Fixes: PAs are often tweaked rather than overhauled.
This cycle creates frustration, burnout, and sometimes worse
patient outcomes — the very opposite of what healthcare should be.
Questioning “Best Practices” in PA Management
Why do we accept that prior authorization has to be a necessary
evil?
- Are
multiple layers of approval truly needed for every medication or
procedure?
- Can clinical
guidelines be trusted enough to reduce manual oversight?
- Should
providers spend 14 hours a week on administrative tasks instead of patient
care?
- How
can insurers and providers work better as partners, not adversaries?
These are tough questions, but necessary for meaningful
reform.
Proof That Change Is Possible
Several states, including Ohio and California, have passed
laws limiting PA requirements or streamlining electronic PA systems with
promising results:
- Reduced
wait times for approval by 40%
- Increased
provider satisfaction scores
- Better
patient adherence to treatment plans
These case studies prove reform is not just wishful thinking
— it’s achievable.
FAQ: Prior Authorization Reform
Q1: What is prior authorization?
A: It’s the process where insurers require approval before certain services,
tests, or medications to ensure medical necessity.
Q2: Why is prior authorization necessary?
A: It helps control costs, avoid unnecessary treatments, and improve patient
safety, but its execution is often inefficient.
Q3: How long does prior authorization usually take?
A: It varies but can take from 24 hours to several weeks, depending on the
insurer and complexity.
Q4: Can providers bypass prior authorization?
A: Rarely. Emergency care typically is exempt, but most non-urgent care
requires approval.
Q5: What can be done to reduce the burden?
A: Automation, standardized criteria, policy reform, and better communication
between providers and payers.
References
- Prior
Authorization Reform in 2025
The American Medical Association (AMA) introduced legislation including the bipartisan Reducing Medically Unnecessary Delays in Care Act of 2025 (H.R. 2433), aiming to ensure only specialty board-certified physicians review treatment decisions. Learn more in the AMA’s National Advocacy Update and ASCO’s policy analysis. - The
Hidden Cost of Prior Authorization
A recent study in JAMA Health Forum explores the economic and clinical impacts of prior authorization delays, highlighting inefficiencies. Details available at JAMA Health Forum and the AMA’s research reports. - Physician
Stories on Prior Authorization Challenges
Firsthand accounts of physicians detailing PA struggles can be found in the AMA’s collection of patient stories influencing lawmakers and KFF Health News’s exploration of insurance denials’ broader impact here.
Call to Action: Get Involved
The time to act is now. Prior authorization reform
affects you, your patients, and the future of healthcare.
Get involved — join the movement, share your stories,
and engage with the community advocating for smarter, faster, and more
compassionate healthcare processes.
- Claim
your spot in shaping policy
- Raise
your hand to reform the system
- Fuel
your growth by learning about the latest tools
- Be
a thought leader on administrative simplification
Let’s do this — together.
About the Author
Dr. Daniel Cham is a physician and medical consultant
with expertise in medical tech, healthcare management, and medical billing. He
focuses on delivering practical insights that help professionals navigate
complex challenges at the intersection of healthcare and medical practice.
Connect with Dr. Cham on LinkedIn to learn more: linkedin.com/in/daniel-cham-md-669036285
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