A Four-Part Roadmap for Responsible Prior Authorization

Prior authorization has been around for a long time. Initially designed in the 1960s as a mechanism to control costs and ensure the appropriate use of medical resources, the goal has (in theory) been to prevent unnecessary procedures and curb wasteful spending. But the reality is that prior authorization has evolved into an administrative quagmire that delays care and frustrates physicians. One survey found that 94% of physicians believe prior authorization leads to delays in care, while 89% say it has a negative impact on clinical outcomes.

The simple truth is that the modern form of prior authorization is a barrier to efficiency and to optimizing quality of care – and our industry faces a moral imperative to fix it. No one body can do it alone. It has become increasingly clear that prior authorization reform is a collective responsibility, requiring support from public and private entities across the healthcare ecosystem. 

An untenable administrative burden

Insurers originally implemented prior authorization as a gatekeeping tool in the face of an explosion of medical advancements, new treatments, and increasing costs. Over time, PA has expanded across nearly every aspect of patient care – medications, diagnostic imaging, surgeries, and inexplicably, even to routine treatments. This has created an enormous administrative burden. According to a recent report from the Council for Affordable Quality Healthcare, the healthcare industry spent $1.3 billion on administrative costs related to PA in 2023. 

It has become untenable. Physicians now spend an average of 13 hours per week navigating PA hurdles. This is time that doctors could be using to treat patients, but instead they’re stuck dealing with red tape. And while PA was designed by insurers to reduce costs, how has that worked out? Administrative waste has been one of many factors driving up healthcare spending, along with the downstream costs of untreated or poorly managed conditions. This stopped being an inconvenience a long time ago: it’s graduated to a public health crisis fueled by systemic friction. Reform is essential—but how we pursue reform will determine whether we fix the problem or simply add new layers of complexity. 

A roadmap for responsible reform: Moving beyond the status quo

To address the prior authorization crisis effectively, we need a comprehensive approach that balances legitimate cost concerns with patient care and provider efficiency. I propose a four-part roadmap to transform prior authorization. It won’t solve every problem with today’s PA processes, but at the very least it will get us moving in the right direction. 

The first step is improving transparency in prior authorization rules and metrics. Current PA criteria tend to be opaque, inconsistent, and difficult for providers to navigate. Payers should be required to publish clear, standardized medical necessity guidelines, updated monthly, so patients and providers know exactly what is required. Guesswork is the enemy of efficiency.  

Additionally, a public payer scorecard should be released each month, displaying submission approval rates, turnaround times and overturn rates on appeal. Data must also be made available via open APIs in order to ensure seamless integration into provider workflows and minimize administrative burdens. Some progress is being made in the industry: the Centers for Medicare & Medicaid Services passed a final rule on streamlining prior authorization processes in 2024, but private industry leaders must now step up with their own reforms. They need to be held to the same standard, building on the existing CMS framework. 

The second step is to eliminate gold-carding. I understand the appeal of exempting trusted parties with good track records from PA requirements. On its surface, gold-carding sounds like a good solution. The logic tracks. But this practice opens up an entirely new can of worms, forcing providers to keep track of different rules for different insurers. By creating another layer of complexity, gold-carding actually undermines the goal of reducing administrative friction and perpetuates a fragmented approach. Rather than picking and choosing which providers are exempt based on criteria determined by insurance providers, payers need to come together to create and adopt universal policies and standards that apply to all providers, with an emphasis on fair and transparent rules. The easiest way to eliminate gold-carding is to render it obsolete. 

Next up is regulation reform. The current status quo is a mess, with a patchwork of regulation that vary from state to state. That’s got to go – we need to replace state-level regulations with a uniform federal policy that applies to all. If you don’t believe me, just go ask someone working in compliance for a national health system or insurer: prior authorization regulations are a nightmare filled with red tape and conflicting requirements. It’s slowing us down and affecting the quality of care patients receive. 

Will it be easy to create a single, federal standard that ensures transparency, timeliness and patient safety? You can pick up any newspaper and ready about the dysfunction in Congress to answer that question. It’ll take real effort, but this is an issue that has garnered bipartisan support and the end result will be worth it: simplified operations, lower compliance costs, and most importantly, ensuring that patients receive consistent treatment – regardless of where they live. 

The final step: we must bring physicians into the loop through technological integration. Interoperability across electronic medical records (EMRs) is a foundational requirement for effective PA, but presently insufficient. API access must be free and universal to ensure all providers can integrate prior authorization data directly into their workflows to reduce friction. As an added bonus, this allows physicians to focus on patient care rather than paperwork. 

Prior authorization reform is no longer an abstract policy debate; it is a necessity for patient safety, physician well-being, and system-wide efficiency. We cannot afford to wait for a perfect solution. The tools exist today to significantly reduce PA’s burden on our healthcare system, we just need to mobilize and implement them. 

Collective will needs to kick in: it’s time for physicians, insurers and policymakers to stop tolerating the problem and start fixing it. Our patients, and our healthcare workforce, have been waiting patiently for a solution, but their tolerance is wearing thin and they deserve better. The time to act is now. 

Photo: sqback, Getty Images

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