PA Reform: Is the Administrative War of Attrition Ending?

Prior authorization (PA) reform has been a long time coming. Will we finally start to see some changes with the passage of the Reducing Medically Unnecessary Delays in Care Act of 2025, the finalization of the Centers for Medicare and Medicaid Services’ (CMS’) Interoperability and Prior Authorization Final Rule in January 2024, the introduction of provider gold cards and payer scorecards, and a shift to electronic authorization systems?

As we have all experienced, the healthcare prior authorization process in the U.S. is broken. The process often feels like a war of attrition between healthcare providers and insurance companies, with patients stuck in the middle. The current PA process is expensive and inefficient; it delays or denies care and negatively impacts the well-being of providers and patients alike. Shouldn’t we all be on the same team, using resources to provide needed high-quality care and not wasting resources in an administrative war of attrition?

The 2024 American Medical Association survey (AMA. https://tinyurl.com/5v52dscr) reported that 40% of physicians have staff who work exclusively on PA. Despite this significant manpower usage, denials are common, and approvals can require appeals, peer-to-peers, and letters of medical necessity, delaying care and wasting valuable healthcare resources. The AMA 2024 survey also reported that 94% of physicians believe PAs impact care, and 18% reported that the need for a PA had led to a life-threatening event.

Using data that insurers submitted to CMS, KFF reported that nearly 50 million PA determinations were made by Medicare Advantage insurers in 2023, and of these, 3.2 million claims were denied, 11.7% of denials were appealed, and 87.7% of denials were ultimately overturned, highlighting the extreme waste of administrative effort in the PA process (KFF. https://tinyurl.com/598w6ue8). The low appeal rate suggests a manpower issue: Providers and healthcare organizations lack the resources to fight the denials. In KFF’s report, 88% of physicians said PAs lead to higher overall utilization of healthcare resources, due to factors such as additional office visits, ineffective initial therapies, and emergency department visits; 90% of physicians reported that the PA process increases burnout.

Currently, the administrative war of attrition continues. Recently, I had a patient’s functional blepharoplasty denied by one insurer; the procedure had previously been approved by another insurer before his job change. A few days before surgery, the insurer had an atypical request for a photo of the patient’s eyebrows taped up despite having the results of his failed visual field testing, clinical photos, two peer-to-peers, a letter of medical necessity, and multiple phone calls by the patient himself to the insurance company over the preceding two months. Unfortunately, despite the patient coming in for the photos, the insurer did not have time to review the photos they requested before surgery. Trying to obtain approval took longer and was more expensive than the surgery, had it been approved, but it wasn’t.

At this year’s annual meeting, the AMA’s House of Delegates discussed the urgent need to generate a PA database to track the cost and impact PA has on patient care. Currently, 50 insurers are working to implement electronic PA by 2027, and more hospitals are using “payer scorecards” to track denials and response times. In the quickly evolving world of AI, a system of immediate PA from insurance should become the new normal. The days of waiting weeks, if not months, for a PA for a common surgical procedure with appropriate documentation need to end. PA delays and denials result in a tremendous number of healthcare dollars wasted on administrative efforts, and a negative impact on OR utilization and patient health.   

—Robin