'Prior Authorization Rules Show Little Consistency Across Major Insurers: Study'

Four major insurers showed almost no overlap in prior authorization requirements and no shared approval criteria or documentation rules, potentially contributing to the time and administrative burden of obtaining treatment approvals, according to a new study published in the Annals of Internal Medicine.

Researchers from Stanford University, Georgetown University, and UnitedHealth Group compared prior authorization policies from Aetna, Humana, UnitedHealthcare, and Anthem California. They found that only about 3% of Healthcare Common Procedure Coding System (HCPCS) billing codes requiring authorization overlapped across all four insurers.

More than half of the codes requiring authorization were unique to a single insurer, and the number of HCPCS billing codes requiring prior authorization varied widely, ranging from 1162 at Aetna to 3048 at Humana, according to the study.

The findings underscore the cumbersome guidelines physicians must navigate when seeking approval for patient care.

“What we found was substantial variation in both the criteria and requirements for prior authorization,” David Scheinker, PhD, study co-author and founder and director of SURF, a systems utilization research group at Stanford Medicine in Stanford, California, told Medscape Medical News. “Although insurers may claim that their contracts are unique and generate value for customers, they are actually the same few rules and ideas applied in just enough different ways to make them difficult to work with.”

Despite dozens of major insurers pledging in 2025 to streamline prior authorization and reduce administrative burdens, physicians continue to dedicate substantial resources to meeting the requirements.

Scheinker pointed to research estimating that providers devote staff time equivalent to more than 100,000 full-time registered nurses annually to prior authorization activities.

The current authorization process can also affect patient care. A recent survey from the American Medical Association found that 95% of physicians said prior authorization delays necessary care, whereas nearly 80% reported patients sometimes abandon recommended treatment because of authorization obstacles.

The study’s researchers said insurers do not necessarily need identical prior authorization policies but argued that the rules should be standardized in digital formats so that electronic systems can manage them more efficiently.

A New Prior Authorization Framework

Historically, comparing insurer prior authorization policies at scale has required labor-intensive manual review because requirements are written differently across plans and states.

Using AI tools to analyze insurer policy language, the study’s researchers built what they described as a proof-of-concept framework to translate complex payer policies into “computable contracts,” or machine-readable rules that electronic systems can quickly review.

“Every insurer can keep exactly the contract they have, but it should be an algorithm a computer can read and process rather than hundreds of pages of contracts in tens of thousands of slightly different versions,” Scheinker said.

Physicians already document the clinical information insurers require during a patient visit, he said. Under the researchers’ envisioned framework, prior authorization approvals could be handled automatically in the electronic medical record before the patient even leaves the office. Scheinker said this flow could reduce the repetitive manual work, typically initiated by additional staff members, that is currently required for routine authorizations.

“The goal is for doctors to stop fighting,” said Scheinker. “Doctors should have a system where they only have to get personally involved once out of every thousand times instead of spending more time on paperwork than they do with their patients.”

The Centers for Medicare & Medicaid Services (CMS) and private insurers have increasingly experimented with electronic and AI-assisted prior authorization workflows, including the federal WISeR model, which uses technology-assisted review for certain Medicare services.

However, the study authors argued that current federal electronic interoperability mandates, including a CMS rule requiring insurers to adopt standardized electronic prior authorization interfaces by 2027, will merely “digitize” the complexity if insurers continue to use different approval criteria and documentation requirements.

Overcoming ‘So Much Fragmentation’

The lack of transparency and coordination across insurers has long complicated prior authorization reform efforts, said Miranda Yaver, PhD, assistant professor of health policy and management at the University of Pittsburgh in Pittsburgh.

“One of the big challenges is that we just have so much fragmentation and opacity,” she told Medscape Medical News.

Congress has previously considered legislation to streamline electronic prior authorization in Medicare Advantage, and another federal proposal — the Stop Deadly Denials Act — was introduced in April. Still, Yaver said federal reform efforts have nevertheless struggled to gain traction. Some states have separately enacted prior authorization reforms through “gold card” programs that reduce requirements for physicians with high approval rates.

Drawing on interviews for her book, Coverage Denied: How Health Insurers Drive Inequality in the United States, she said many physicians are skeptical of prior authorization reform, especially measures that prioritize faster processing rather than reducing inappropriate denials.

“The general sentiment I came across was, ‘I don’t need a timelier denial. I need an approval for the medically necessary care I’m prescribing,’” Yaver said.

She said some healthcare systems have begun using real-time prescription benefit tools embedded within electronic medical records that allow physicians to check formulary status, prior authorization requirements, and patient cost-sharing during appointments, though adoption remains uneven.

Yaver said another option for reform would be to implement prior authorization that is more narrowly focused on areas with clear evidence of overutilization, such as MRI lumbar imaging.

Rather than requiring routine prior authorization across many areas of care, insurers could rely more heavily on targeted audits of outlier prescribing patterns, Yaver said. “Then have prior authorization essentially be a penalty, a watchful eye for a couple of years, instead of this broad-based barrier to care for patients that contributes to physician burnout and burden.”

State insurance commissioners could also bypass the need for congressional action and require insurers to adopt standardized digital frameworks for prior authorization rules, said Scheinker. Meanwhile, he hopes the open-source database and algorithms developed for the study will help more researchers systematically compare insurer policies.

“Next, we’re actually examining how well the different insurance company requirements line up with the clinical evidence,” he said. “Spoiler: There’s no way for it to be totally consistent with the evidence and be so inconsistent across insurers.”

https://www.medscape.com/viewarticle/prior-authorization-rules-show-little-consistency-across-2026a1000ghs