Payors have long defended prior authorization as a tool to ensure the right care happens at the right time and in the right place.
The long-standing evidence is making that argument harder to defend.
Medicare Advantage plans denied 4.1 million prior authorization requests in 2024. Patients and providers appealed only 11.5% of those denials. When they did appeal, 80.7% were partially or fully overturned.
That leaves a pretty important question about the other 88.5%.
Were those denials correct? Or did patients and providers decide that fighting the insurance company wasn’t worth the time and delay? We don’t know. But we do know that 79% of physicians say prior authorization sometimes causes patients to abandon recommended treatment, while 95% say it delays necessary care.
Patients tell a similar story. Patients who had prior authorization challenges were about 3x as likely to report being unable to receive care their provider recommended and 3x as likely to experience significant delays. KFF appropriately notes that respondents could report multiple insurance problems, so prior authorization can’t be isolated as the cause in every case.
Then came another remarkable number. In June, the Department of Health and Human Services Office of Inspector General reported that Medicare Advantage plans overturned 95% of appealed prior authorization denials for skilled nursing facility admissions.
Prior authorization reform is no longer a theoretical conversation. It has to change, and soon!
Massachusetts prior authorization reform needs a closer look
Massachusetts recently amended its managed care regulations to eliminate prior authorization for a list of routine and essential services in fully insured plans. The changes took effect June 5, 2026.
On its face, the list sounds substantial: emergency and urgent care, primary and preventive care, maternity services, physical and occupational therapy, outpatient substance use disorder treatment, certain medications, chronic disease management, and specified cancer imaging.
Let’s get precise about what changed.
Emergency care is, by definition, not something most people schedule while waiting for an insurer to approve it. So what administrative requirement was Massachusetts actually eliminating? Was the issue prior authorization, notification after the fact, or another requirement that could ultimately affect coverage or payment?
Maternity deserves the same scrutiny. Federal law already provides protections around authorization for childbirth and required hospital stays. What additional administrative work does the Massachusetts regulation eliminate? What pregnancy or admission notification requirements remain?
Then there’s imaging following a cancer diagnosis. Which imaging? Does the exemption apply to a defined list of CPT codes? Who determines whether the imaging qualifies as staging or treatment planning? Can a plan still apply frequency limits, site-of-service requirements, medical-necessity edits, or retrospective review?
These are more than just semantics, they’re the mechanics of coverage for care.
We’ve seen what happens when policy meets claims administration
The Affordable Care Act’s preventive-care mandate gave us a useful preview of why precision matters. The law required recommended preventive services to be covered without patient cost sharing. Then the policy met claims administration.
What happens when a screening colonoscopy finds a polyp?
Apparently, someone needed to answer that question. In 2013, the Departments of Labor, Health and Human Services, and Treasury had to clarify that polyp removal is an integral part of a screening colonoscopy. A plan couldn’t suddenly impose cost sharing because the physician found something and removed it. Clinically, that seems obvious, and it’s hard enough to get people to have screening colonoscopies in the first place.
Similar questions emerged as preventive technology changed. If a coverage requirement says mammography, which mammography does that mean? Does it include newer 3D technology or only conventional mammography? The distinction may look technical inside a claims department, but it can mean hundreds of dollars to the person getting screened.
This is the risk with prior authorization reform. The regulation says one thing. Then the regulation meets the claims manual.
Fewer prior authorizations don’t necessarily mean fewer restrictions
In 2025, roughly 60 insurers announced commitments to reduce prior authorization requirements, improve transparency, protect continuity when patients change plans, and increase electronic prior authorization. Yet physicians have heard similar promises before. Only 33% of physicians surveyed by the AMA believe the latest commitments will make a meaningful difference.
Their skepticism has some history behind it. Physicians and their staffs still complete an average of 40 prior authorizations a week and spend about 13 hours doing it. 40% of physicians employ staff dedicated exclusively to prior authorization.
UnitedHealthcare recently announced that it will eliminate 30% of its remaining prior authorization requirements by the end of 2026. The company specifically mentioned select outpatient surgeries, echocardiograms, outpatient therapies, and chiropractic care. Thirty percent sounds significant. Providers should look at what disappears along with the authorization.
Take chiropractic care. Utilization can already be controlled through visit limits and benefit changes. If prior authorization disappears but the visit limit stays exactly where it was, what changed for the patient? The payor no longer has to administer the authorization. That certainly reduces somebody’s administrative burden.
Physical therapy raises another question. Which CPT codes count against which benefit limits? Could services delivered by a physical therapist count against both a therapy limit and another benefit limit depending on the codes billed?
Removing the prior authorization requirement tells us that one mechanism disappeared. It doesn’t tell us that the underlying utilization constraint disappeared with it.
That distinction should matter to anyone evaluating prior authorization reform.
Electronic prior authorization may make the process faster. For whom?
Automation and interoperability are another major part of the industry’s reform promises.
Electronic submission, real-time status information, and faster decisions could eliminate enormous amounts of provider work. Anyone who has spent time sending clinical records into a portal, checking authorization status, or waiting on hold should welcome that. But there’s another possibility.
Automation makes utilization management cheaper and easier for payors to administer, too.
UnitedHealthcare is reducing prior authorization requirements while also investing in electronic submission and faster decisions. CMS is pushing the industry toward standardized application programming interfaces to exchange prior authorization information.
Those changes can improve interoperability. The question is what the industry does with the efficiency.
If a provider can submit the same unnecessary request in 30 seconds instead of 10 minutes, we reduced some burden. We didn’t establish why the request exists.
If artificial intelligence can evaluate thousands of requests faster than a clinical review team, we improved throughput. We didn’t establish that the decisions improved. 6 in 10 physicians in the latest AMA survey expressed concern that AI could increase prior authorization denials.
We’ve written about this problem before. AI can remove administrative burden when providers use it to automate documentation, coding, and revenue cycle work. In payor utilization management, the same technology can make it possible to apply administrative controls faster and at greater scale. Efficiency is only useful if we’re clear about who benefits from it.
What providers should measure after prior authorization reform
This is why providers need to measure more than prior authorization volume.
Track authorizations before and after reform. Then track what happens around them: notifications, visit and frequency limits, concurrent reviews, retrospective medical-necessity reviews, medical-record requests, claims edits, site-of-service restrictions, denials, appeals, overturn rates, payment delays, and staff time. Follow the work.
A payor can reduce prior authorization without reducing utilization management. And it can change utilization management without reducing the administrative burden on providers. Those are three different things.
If prior authorization volume falls 30% while retrospective reviews and medical-record requests climb, that isn’t the same as eliminating 30% of the work. If notification replaces authorization and requires essentially the same information, providers should know it.
And if a visit limit was already controlling utilization while prior authorization simply added another administrative layer, providers should know who actually benefits when that layer disappears.
The data have value beyond operations. Bring them to the negotiating table. Use them to support additional exemptions, eliminate duplicative requirements, change notification provisions, challenge unnecessary documentation, and negotiate protections against retrospective review.
Bring them to policymakers, too. Massachusetts has created an opportunity to see what happens when prior authorization requirements disappear. Providers can help determine whether the barriers disappear with them.
We’ve argued that financial and insurance complexity can become an access issue. Prior authorization is a particularly direct example: administrative decisions can determine whether physician-ordered care happens, when it happens, and sometimes whether the patient continues pursuing it at all. Don’t measure prior authorization reform by the number of requirements a payor says it eliminated. Measure what changed for the physician trying to deliver care and the patient trying to receive it. That’s where we’ll find out whether prior authorization reform actually removed a barrier or just gave it a new name.
