Prior Authorization Burden Grows, Change Momentum Builds
- Through prior authorization, insurance companies erect barriers to treatment—and even the sickest patients do not escape this ordeal.
- Cancer patients, in particular, suffer the most from the delays and denials in treatment.
- "Of all the patients and all the conditions that we care for, cancer patients are probably some of the ones for whom the delays and the denials and...
Table of Contents
- As Prior Authorization Burdens Grow, Momentum for Change Continues to Build
- The Impact on Cancer Patients
- Insurance Companies and Patient Care
- The Role of the Insurance Company: A Third Person in the Exam Room
- Ron Howrigon: Inspections and Preventing Care Compromisation
- The Big Picture: Policy and Legislative Efforts
- T. Christian Miller and Patient Advocacy
- The Way Forward
- The Power of Data: Informing Policy
- Action Steps for Physicians
- Conclusion
- As Prior Authorization Burdens Grow, Momentum for Change Continues to Build
- frequently Asked Questions about Prior Authorization in Healthcare
- 1. What is Prior Authorization, and How Does it Affect Patients?
- 2. How Does Prior authorization Specifically affect Cancer Patients?
- 3. What Are the Consequences of Prior authorization Delays on Patient Care?
- 4.How Are Insurance Companies Justified in Using Prior Authorization?
- 5. What Legislative and Policy Efforts Are Being Made to Address Prior Authorization Issues?
- 6. How Can physicians and Advocates Contribute to Prior Authorization Reform?
- 7.What Role Does Data Play in Advocating for Prior Authorization Reform?
- frequently Asked Questions about Prior Authorization in Healthcare
Through prior authorization, insurance companies erect barriers to treatment—and even the sickest patients do not escape this ordeal. According to a panel discussion on prior authorization at the February 2025 AMA State Advocacy Summit in Carlsbad, California, the burden of prior authorization is increasing, affecting patients across the country.
The Impact on Cancer Patients
Cancer patients, in particular, suffer the most from the delays and denials in treatment. Bruce A. Scott, MD, the president of the AMA, moderated the panel and emphasized the severe impact of these delays. He highlighted that the denials from doctors and treatments being labeled as “experimental” have a profound effect on cancer patients.
“Of all the patients and all the conditions that we care for, cancer patients are probably some of the ones for whom the delays and the denials and the claim of ‘that’s experimental’ has probably the greatest impact.”
AMA President Bruce A. Scott, MD
Insurance Companies and Patient Care
Panelist Lucy Culp, the vice president for state government affairs at The Leukemia & Lymphoma Society, testifies that prior authorization delays are worsening. Culp remarked that patients’ battles with insurance companies are ubiquitous, with prior authorization being a top concern.
Culp narrated an example from Wisconsin, where a cancer patient was prescribed 12 rounds of chemotherapy, each requiring separate prior authorizations. This intricate process is not isolated and reflects the broader challenges patients encounter.
“The evidence is really clear that the prior authorization volume continues to increase.”
Lucy Culp
The Role of the Insurance Company: A Third Person in the Exam Room
The overuse of prior authorization by insurance companies poses genuine risks to patients, sometimes even leading to severe harm and death. Nearly 25% of the 1,000 physicians the AMA surveyed in 2023 reported that prior authorization resulted in serious adverse events for their patients. These events included permanent bodily damage and death. The AMA, recognizing these severe impacts, is actively fighting to eliminate delays, patient harm, and practice hassles.
“Because these are not just incredibly complicated-to-treat diseases, they’re extraordinarily expensive to treat, which means that unless you are Warren Buffet-level wealthy, you are relying on insurance to access your care,” Culp said. “It’s a third person in the exam room”,
Lucy Culp, vice president for state government affairs, The Leukemia & Lymphoma Society.
Ron Howrigon: Inspections and Preventing Care Compromisation
Ron Howrigon, CEO of Fulcrum Strategies, emphasized that the trend is worsening and predicted the same continuing trajectory. He cited the stock price of UnitedHealth Group, which rose from $7.50 a share 25 years ago to $520. The pressure to maintain and accelerate this growth is immense, leading insurers to implement stringent prior authorization processes.
“The most egregious stuff are things you can’t make up,”
Ron Howrigon
Howrigon shared a recent example where a rheumatology group reported a prescription for a biosimilar being denied. The approved alternative was not available for months, leading to significant delays in patient care. These challenges are pervasive and affect every physician practicing in the U.S. today.
The Big Picture: Policy and Legislative Efforts
Across the country, several lawmakers are actively fighting against unfair prior authorization practices.
For instance, over 30 states have introduced legislation in 2024 to reform various aspects of the prior authorization process. Additionally, substantial federal regulatory changes have been implemented to cut care delays and streamline the process for Medicare Advantage and other federal health plans. These reforms are set to save physician practices a massive $15 billion over a decade, according to the AMA Resource Center.
T. Christian Miller and Patient Advocacy
Journalist T. Christian Miller shed light on the power of patient stories in influencing public opinion and policy. Miller’s article on How the Cigna-owned company, Evicore by Evernorth, promised client companies that, for every dollar they paid Entercore, they would pay out $3 fewer in claims.
illustrated how significant individual patient stories can be. These stories are pivotal in moving legislative agendas and public advocacy efforts.
“Those are the stories, the individual pieces, that move mountains—and then you can back that up with data that shows this is not a unique or one-off case. And that begins to attract the attention of the influencers, the policymakers, who see this as not just an aberration but a pattern.”
T. Christian Miller, a journalist with the nonprofit news organization ProPublica.
The Way Forward
A majority of the members of the Congress did sign into official co-sponsorship for the bipartisan Improving Seniors’ Timely Access to Care Act of 2024 (H.R. 8702). However, it remains to be seen if these efforts will materialize and significantly impact how insurers manage prior authorizations for patients in 2025.
The Power of Data: Informing Policy
While storytelling holds immense power, data-driven insights are equally critical. Legislative bodies must be appraised with accurate, granular, and timely statistics that underscore the extent of the current situation. In recent years, around 3.2 million prior authorization requests were denied in 2023 alone, according to a KFF Report. Of those, a mere 11.7% of Medicare Advantage denials were appealed, yet 81.7% of those appeals were successful. These numbers reveal consistent success in overturning denial cases.
Action Steps for Physicians
The AMA urges physicians to actively engage in the advocacy efforts by sharing their experiences with prior authorization on the AMA advocacy website, Situations of undue hardships and consequences can shine much-needed light on the existing processes and push for reforms through policy and legislative pathways. The AMA is committed to harnessing medical written documents to actionable political action and bring about systemic changes, doctors should go the extra mile to speak up one voice per their actions.
Conclusion
The fight against stringent prior authorization practices by insurance companies continues. With mounting evidence and compelling patient stories, legislators are taking note and taking steps to reform this burdensome system. Continued advocacy, sharing patient stories, and pushing for legislative change are essential steps in ensuring that prior authorization processes prioritize patient care above all else.
- Question: What is prior authorization, and how does it impact patients’ access to healthcare?
- Answer: Prior authorization is a cost-control process used by insurance companies that requires healthcare providers to get approval before delivering certain treatments or medications to patients. This places a barrier between patients and timely care, frequently enough leading to delays and, in certain specific cases, patients not receiving necessary treatments.The onus is on healthcare providers to justify the need for specific procedures or drugs, which can result in meaningful administrative burdens and increased healthcare costs for patients.
- Question: Why are cancer patients particularly affected by prior authorization processes?
- Answer: Cancer patients face significant delays and treatment denials due to prior authorization. These patients frequently enough require timely access to medications and treatments, and any delay can have dire consequences. This process also frequently results in treatments being labeled as “experimental,” further complicating access.Testimonies from experts like AMA President Bruce A. Scott, MD, highlight that cancer patients experience one of the most severe impacts from these barriers, which can delay life-saving treatments and lead to adverse health outcomes.
- Question: What are the potential risks associated with prior authorization delays and denials?
- Answer: Prior authorization delays can lead to serious health risks, including permanent bodily harm and even death. According to a survey by the AMA in 2023, nearly 25% of physicians reported that prior authorization resulted in severe adverse events for their patients. These delays interfere with the immediate needs of patients, often placing financial and administrative obstacles in the path of urgent and necessary treatments.
- Question: What reasons do insurance companies provide for utilizing prior authorization, and what are the criticisms of this approach?
- Answer: Insurance companies argue that prior authorization helps control costs and ensures that patients receive appropriate care. However, critics like Lucy Culp from the Leukemia & Lymphoma Society argue that it often acts as a gatekeeping method that adds a third party into the doctor-patient relationship, undermining patient care. This system can be particularly burdensome for treating expensive but necessary conditions, shifting the financial responsibility onto insurers.
- Question: What legislative or policy changes are currently being pursued to reform prior authorization processes?
- Answer: Significant efforts are in place to reform prior authorization. In 2024, over 30 states introduced legislation aimed at improving this system. Moreover, federal changes have been implemented for Medicare Advantage and other federal health plans to reduce care delays, as reported by the AMA resource center. Legislative initiatives, such as the Improving Seniors’ Timely Access to Care Act of 2024 (H.R. 8702), highlight the bipartisan support for change, although its passage remains uncertain.
- Question: what actions can physicians and patient advocates take to help reform prior authorization practices?
- Answer: Physicians are encouraged to share their experiences with prior authorization on platforms like the AMA advocacy website. By documenting and highlighting specific cases of undue hardships, they can provide valuable insights and push for meaningful reform. Additionally,storytelling and data-driven advocacy by journalists like T. christian Miller of ProPublica illuminate the impact of these practices and contribute to influencing policy changes.
- Question: How is data being used to support advocacy for the reform of prior authorization?
- Answer: Data plays a crucial role in driving reform efforts. Reliable statistics from sources like the KFF Report indicate the high denial rates of prior authorization requests and the success rates of appeals, which can be powerful tools for advocacy. By presenting precise data, legislative bodies can be persuaded with clear evidence of the current system’s inefficacy and the potential benefits of reform.
Note: The above content was crafted for educational purposes, aiming to inform about the ongoing challenges and responses related to prior authorization in healthcare. For further and the most current details, consultation with authoritative and updated sources is recommended.