For nearly as long as health insurers have used prior authorization to control costs, physicians and hospitals have argued it does more harm than good.
The pushback against prior authorization has reached new heights in recent months as healthcare leadership, legislators and physician advocacy organizations have proposed major reforms or outright bans of the practice.
Here are 10 notes on where things stand.
1. A health insurance CEO says prior authorization should be illegal. Patrick Quigley, CEO of El Segundo, Calif.-based Sidecar Health, told Becker’s that the industry’s signature cost-control tool creates more waste than it prevents.
“We are creating massive amounts of waste in our system, and we are controlling cost within the system simply by denying care,” he said.
Mr. Quigley argued the fix isn’t reforming prior authorization — it’s eliminating it. “The right path is actually to stop and make prior authorization illegal,” he said. “Why do we need prior authorization at all? Instead, focus on creating transparency around decisions, around costs, around quality, so that people can naturally make better decisions, because that’s going to lower costs.”
2. The denial data behind his frustration is now public. Under new reporting requirements, Medicare Advantage, Medicaid managed care and ACA marketplace plans must publicly disclose how often they deny prior authorization requests and how often those denials get overturned on appeal. A KFF analysis found denial rates ranging from 12% to 18% across the three markets, while appeal overturn rates hit 67% for Medicare Advantage, 47% for Medicaid and 43% on the marketplace — including one insurer, Centene, that overturned 93% of its appealed Medicare Advantage denials. About 150 million Americans with employer-sponsored coverage aren’t captured by the reporting requirement at all.
3. The lack of transparency around prior auth has a price tag. A policy brief from the American Economic Liberties Project, cited alongside Mr. Quigley’s case for banning prior authorization, put the administrative burden created by the process at the equivalent of more than 99,000 full-time clinicians and up to $32.7 billion a year.
4. CMS just closed transparency loopholes the AMA says insurers were exploiting. The 2024 Interoperability and Prior Authorization rule requires health plans to publicly post their prior authorization requirements and outcomes. But when the American Medical Association reviewed 15 Medicare Advantage contracts, it found plans technically complying while making the information nearly impossible to use — hundreds of pages of billing codes with no plain-language explanation, disclosures buried behind password-protected portals, and entire categories of care omitted altogether.
“Patients should not need a portal password, a billing manual or medical training to find and understand a health plan’s prior authorization practices,” said Willie Underwood III, MD, president of the American Medical Association.
Following the AMA’s findings, CMS updated its guidance to clarify that password-protected portals don’t satisfy disclosure requirements and to require plain-language descriptions, standardized service categories and machine-readable formats. Dr. Underwood called it “an important step,” but said “the work is not finished.”
5. Insurers say their pledges are working. Physicians see something different. About 50 insurers covering 257 million Americans committed in June 2025 to streamline prior authorization. AHIP and the Blue Cross Blue Shield Association have since reported an 11% reduction in requirements, with some Medicare Advantage plans exceeding 15%.
“During the past 10 months, the Blues made significant, measurable strides toward delivering on our promise to make this process faster, simpler and more transparent,” said Kim Keck, CEO of the Chicago-based Blue Cross Blue Shield Association.
Physicians report a different reality. In an AMA survey, 94% said prior authorization negatively affects patient outcomes, and just 1% reported a positive impact; 26% documented serious adverse events tied to a delay or denial, including hospitalization (23%), a life-threatening event (18%) or disability or death (8%). Among physicians who contract with UnitedHealthcare and Cigna — two insurers that pledged reform — only 16% said they’d actually seen requirements decrease.
6. For ASCs, the burden is growing, not shrinking. In 2024, 46% of ASC cases required prior authorization, up from 42% the year before — and only 24% of those authorizations were completed on the first attempt.
7. Insurers’ own finances help explain the squeeze. Seventy-three percent of health plans reported operating losses in 2025. Over the same period, 54% of revenue cycle leaders said claim denials are increasing, and 41% said at least 1 in 10 claims are now being rejected — the same dynamic Mr. Quigley described insurers using prior authorization to manage.
8. Washington’s AI-driven fix is facing bipartisan pushback. CMS’s WISeR (Wasteful and Inappropriate Service Reduction) pilot, which uses artificial intelligence to review Medicare claims, launched Jan. 1 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington and is set to run through 2031. The House Appropriations Committee voted June 9 to block its funding, and 31 House Democrats have asked CMS for pilot data, citing reports of denials and longer wait times. A report from Sen. Maria Cantwell, D-Wash., found authorization wait times in pilot states have grown two to four times longer — to 10 to 15 days, from one to two days before the program began.
9. States aren’t waiting on Washington. A Massachusetts law that took effect June 5 restricts prior authorization for roughly half of the state’s commercially insured residents, prohibiting it for emergency and urgent care, primary care, imaging after a cancer diagnosis, preventive services, maternity care and substance use disorder treatment.
10. One reform meant to ease the burden is under utilized. Gold-carding programs exempt physicians with strong approval track records from prior authorization altogether. But only 10% of physicians contract with health plans that offer one. In the meantime, practices complete an average of 39 prior authorizations per physician each week, spend 13 hours on the paperwork, and in 40% of cases employ staff whose job is dedicated to prior authorization alone.
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