A number of the nation’s insurers said Friday that they would stop using strict prior authorization, a tactic that delays and denies medical care. But the announcement immediately brought questions and even ridicule from people in the healthcare system.
The announcement came amidst rising anger from patients and doctors about medical treatments that are denied by prior authorization. This is the practice required by many insurers: Doctor prescribes a procedure or drug, requests authorization from the insurer that it can go ahead, and then proceeds — or not, if the request is denied.
“In making the announcement, executives from the two main insurance trade groups acknowledged that the growing outcry over the process and said that the plans promised to take a series of voluntary steps over the next year and a half,” Reed Abelson wrote for The New York Times. ‘We recognize the frustration people often feel about their experience,’ said Mike Tuffin, the chief executive of AHIP, an industry trade group in Washington, D.C. By easing the policies, he said, ‘we expect patients will feel less friction and more peace of mind.’”
The announcement instantly raised skepticism and even ridicule among people in the world of healthcare. The practice of prior authorization is widely believed to be at the center of insurers’ business models: Collect insurance premiums, and then figure out a way to refuse to pay for healthcare, often throwing a patient into a crisis in which they cannot get the care their doctor prescribed without agreeing to pay out of pocket. So — is this for real? A number of people in a healthcare community I am in scoffed.
‘Post-claim denial’?
“So will the prior authorization process with denials then become a post-claim denial that results in balance bills?” Matt Henderson, a client executive with Oakbridge, a benefits platform, wrote in the forum. “Or hospitals refusing to proceed without a guarantee of payment from the patient?”
Dr. Owen Muir, a New York psychiatrist who treats adults and children and also writes about healthcare at TheFrontierPsychiatrists, wrote: “The degree to which I believe them is not at all. It’s gonna turn into pre-payment review, and they will emphasize how much prior authorization is not a guarantee of treatment.”
Anger over prior authorization has also been described as a factor in the murder last year of Brian Thompson, a UnitedHealthcare executive, which led to an outpouring of complaints and reports from Americans who had seen treatments for themselves and their families denied, despite being recommended by doctors, sometimes with catastrophic results. Lawmakers, doctors, trade groups and others have expressed anger over the system.
Insurers say their role is to hold down costs by paying only for tried and true treatments, instead of throwing money at everything doctors prescribe, and approving only the medications they think are proper. This brings doctors to complain that the insurers are overruling doctors and practicing medicine without a license. At the same time, insurers are reaping huge profits, drawing fire from people who think prior authorization is simply a game.
“Insurers often send unintelligible form letters, leaving patients to puzzle out the basis for the denial or what their next steps should be. Patients may delay or even abandon necessary medical care because they may not even be aware that they can appeal the decisions,” Abelson wrote.
‘So ridiculous’
Commenting on the announcement, Dr. Sunit Jolly, a longtime chiropractor who consults with chiropractic and physical therapy clinics at Jolly DC Consulting, wrote: “As someone who has been working in the Chiropractic and Physical therapy space for 20 years, we have seen a shift towards mid-care authorizations.
“A patient may get 5 visits and then need an authorization. Then if we are lucky, they get approved for 5 more visits and then we are required to submit again. It’s disruptive for the patient’s care, because we often have to stop treatment while waiting to see if they are going to get approved. The authorization process is so ridiculous. We hire someone dedicated to do it full time and since health insurance reimbursement never pays providers more to do this service, it comes out of the provider’s reimbursement for the service. If they get rid of prior auths, they will find another way to deny care or make it a hassle to request care. “
John Hennessy, a principal at Valuate Health Consultancy, wrote: “Having spent plenty of time running oncology practices, we see the upsides and downsides of PA processes every day. I’m quite certain that if PAs were to go away, it would be difficult for these practices to pull $30K +/- worth of systemic therapy off the shelf without some prospective guarantee of payment. That could theoretically be accomplished by a thorough benefits investigation and a transparent coverage/pathways policy.
Paul Holmes, a lawyer specializing in pharmacy benefit manager contracting for plan sponsors, wrote: “I suspect they will drop the PAs on unnecessary, high cost surgical procedures. Taking a page out of the PBM playbook.”
‘Outliers’ label
Dr. Paula Muto, a vascular surgeon in the greater Boston area and founder of a cash-price company called Uberdoc, wrote: “At the risk of sounding like one of those shifty doctors, please show me any data over 20 plus years that the cost of prior auths actually lowered costs for the patient. Prior auths and denials are marketing strategies to convince employers that someone is working to keep the costs in check. But it doesn’t work any better than retrospective claim review, meaning doctors within a community who are labeled ‘outliers,’ like 10x Mohs procedures. Doctors don’t want to be called an outlier.
“Consolidation probably makes it more palatable. But the money needed to deny care is now more than you need to pay for it. So why bother? The only one who should authorize care is the patient, and it’s time all of the stakeholders reveal how much of the dollar actually goes to care and how much to manage it.
Abelson wrote: “Dozens of insurers have signed on to the new agreement. The companies include Aetna, Cigna, Kaiser Permanente, UnitedHealthcare and Blue Cross plans in nearly every state, and they cover some 260 million Americans. While there will be some variation in different states and among different employers, the changes apply to both employer-based and government plans under Medicare and Medicaid.
“The insurers said they had agreed to streamline the process to ensure patients and their doctors get a decision about the treatment when the request is made, saying they hope to answer 80 percent of requests in real time by 2027.”
Two members of the online group recalled that UnitedHealthcare said in the early 2000’s that it would stop using utilization management and prior authorization, which are basically two ends of the same horse. They said the commitment ended quickly, without fanfare.
H.H.S. claims credit
On Monday, Robert F. Kennedy Jr., secretary of health and human services, claimed credit for obtaining the commitment from the insurers. He described it not as an end to prior authorization, but a landmark achievement — a commitment to streamline the process.
Insurers will need to provide easily understood explanations for denials, and to have medical professionals review all denials, he said. This is the stated process used by insurance companies, but in the real world, there has been a lot of reporting about denials by artificial intelligence.
A recent Kaiser Family Foundation study “found that 16% of all insured adults in the past year experienced prior authorization problems; and consumers with certain characteristics are more likely to encounter such problems,” KFF reported.
More skepticism
Industry insiders, analyzing the news, were skeptical too.
Christine Deacon of Versan Consulting made some predictions on LinkedIn:
“PAs are reduced — but only for certain providers. If you are owned by the insurer, or if you’re in the insurer’s favored network, you may suddenly enjoy a frictionless experience. Everyone else—especially those out-of-network or less ‘strategically aligned’ — may see no substantive change.
“Could insurers creatively begin charging providers for PA exemptions? There’s precedent here as some already offer ‘delegated utilization management”’ arrangements for a fee. Will these reforms quietly create a new revenue stream while shifting administrative burden? I think so.
“Retrospective denials and adjustments may ramp up. Without robust front-end controls, insurers may simply rely more heavily on post-service claims review — denying or adjusting payments after care has been delivered. This risks increasing financial exposure for providers and patients.
“Self-funded purchasers, unless actively monitoring the full spectrum of claims data and denial patterns, will have no visibility into whether these changes have improved access, lowered cost, or simply shifted the burden. They may also lose the opportunity to use the PA trigger to shift members to more cost effective or appropriate care settings, to seek a second opinion, or to take advantage of a plan design that reduces their cost for engagement with a certain program.”
Whistleblower reacts
Wendelll Potter, a former Cigna public relations executive turned whistleblower, also expressed skepticism on his “Healthcare Uncovered” Substack newsletter. He wrote:
“So naturally, the industry’s ‘commitments’ deserve closer scrutiny. Let’s unpack them. As a former health insurance industry executive, I speak their language, so allow me to translate. AHIP, which has no enforcement power, by the way, claims that 48 large insurers will:
- Develop and implement standards for electronic prior authorization using Fast Healthcare Interoperability Resources Application Programming Interfaces (FHIR APIs).Translation: CMS is already requiring all insurers to do this by 2027. We might as well take credit preemptively.
- Reduce the volume of in-network medical authorizations.Translation: We already demand hundreds of millions of unnecessary prior authorizations for thousands of procedures and services, so cutting a few (who knows how many?) should be a layup and won’t cut into profits.
- Enhance continuity of care when patients change health plans by honoring a PA decision for a 90-day transition period starting in 2026.Translation: We’re already required to do this in Medicare Advantage. And since we delayed implementation of e-authorization until 2027, we’re in the clear until then anyway.
- Improve communications by providing members with clear explanations for authorization determinations and support for appeals.Translation: We’re already required by state and federal law to do this. We’ll double-check our materials.
- Ensure 80% of prior authorizations are processed in real time and expand new API standards to all lines of business.Translation: We had to promise to hold ourselves accountable to at least one measurable goal. We will set the denominator – we’ll decide which procedures and medications require PA – so we’ll hit this goal, no problem, and we might even use more non-human AI algorithms to do it.
- Ensuring medical review of non-approved requests.Translation: People will be relieved we’re not using robots. And we’ll avoid having Congress insist that reviews must be done by a same-specialty physician, as proposed in the Reducing Medically Unnecessary Delays in Care Act of 2025 (H.R. 2433).
