Under pressure from politicians, American health insurers say they’ve voluntarily slashed prior authorization (PA) requirements for medical services by 11% this year. But they’re refusing to provide specifics, and they’re not being greeted as liberators.
“The information is frustratingly vague,” said Sabin Dang, MD, retinal specialist in St. Louis and critic of PA requirements. “If insurers want credit for reform, they should be transparent enough for independent verification.”
And, as he noted, the 11% cutback doesn’t apply to prior auth requirements for prescription drugs. “For many physicians, medication PA is the real burden. This is also where patients can experience the most dangerous delays.”
A representative of medical groups, a health policy researcher, and a neurologist who studies PA expressed similar concerns in interviews with Medscape Medical News.
“Anytime that you can reduce the number of prior authorization requests going through the system is a benefit. But we’re past the point of voluntary measures, and an 11% reduction is barely scratching the surface,” said Darryl Drevna, senior director of Regulatory Affairs with the American Medical Group Association, which represents 400 medical groups and health systems.
Insurers’ PA Mandates Under Fire
The claim by insurers about a reduction in PA mandates came last week in a statement from AHIP, a trade association formerly known as America’s Health Insurance Plans. It’s a follow-up to an insurer pledge last year to embrace voluntary PA reform.
PA mandates are under fire from physicians, patients, and federal and state officials who claim the system is overused and dangerous. “Our consumer polling indicates that other than cost, prior authorization is the biggest hurdle in accessing care,” said Kaye L. Pestaina, JD, director of KFF’s Program on Patient and Consumer Protection.
A 2022 American Medical Association survey of 1000 physicians reported that 94% said PA demands at least sometimes lead to delays in care, and 7% said it “resulted in a serious adverse event leading to a patient’s disability, permanent bodily damage, congenital anomaly, birth defect, or death.”
And while an AHIP survey claimed 96% of prescription drug claims and 93% of medical claims are not subject to PA, a 2025 KFF report found that “virtually all enrollees in Medicare Advantage (99%) are required to obtain prior authorization for some services.”
The AHIP report also revealed commercial plans have PA denial rates of 3% for medical services and 10% for prescription medicines.
What the Insurers Are Saying
The new AHIP statement says leading insurers have “eliminated 11% of prior authorizations across a range of medical services, representing 6.5 million fewer prior authorizations for patients.”
According to AHIP, the 11% number is from an “AHIP-Blue Cross Blue Shield Association survey of health plans participating in the commitments, and it includes “a reduction of more than 15% in Medicare Advantage.”
But AHIP declined to release the survey.
Insurers also announced PA reforms regarding continuity of care and communications with customers.
What the Insurers Aren’t Saying
In response to questions from Medscape Medical News, AHIP provided this limited information:
- The 11% and 6.5 million numbers refer to PA mandates for medical services, including mental or behavioral health, imaging, cardiology, otolaryngology, radiology, and other routine care.
No other specifics about services were provided, however, and the numbers don’t include PA mandates for prescription medicines.
- The numbers reflect a reduction in PAs in 2026 vs 2024 claim volume, “reflective of those CPT [Current Procedural Terminology] codes that would no longer be subject to PA and the claims associated with them.”
The numbers suggest that 59.1 million claims for medical services required PAs in 2024 because 11% of 59.1 million is 6.5 million.
- The statement says, “Services removed from prior authorization include those with clear, evidence-based clinical guidelines, demonstrated improvements in patient outcomes, and consistent utilization patterns among providers.”
AHIP, however, declined to provide specific examples of eliminated mandates or explain why these services required PA in the first place.
As for individual insurers, they have provided variable details about their reforms, said KFF’s Pestaina.
“Some insurers note that they have removed prior authorization requirements for a certain number of service codes without saying what services those codes represent,” she said. “Other insurers just mention overall reductions in ‘common’ procedures. A couple carriers mention removal of some prior authorization for services such as outpatient imaging and echocardiograms.”
Physician Remains Unimpressed
Dang, the retinal specialist, said the insurers should “show us which CPT codes will be removed, how many claims those codes represented per plan, and what the approval rate was before removal. If the approval rate was already 90%-plus, removing the PA requirement was just eliminating paperwork that never should have existed.”
As for the lack of information about PA requirements for prescription drugs, he noted that “within my field of retina, a delay in medication prior authorization could result in blindness, as diseases such as diabetes and macular degeneration can be time-sensitive.”
Dang led a 2024 study that found 96.2% of 2225 PA requests were approved for anti-VEGF drugs, which treat serious eye conditions such as neovascular “wet” age-related macular degeneration, diabetic retinopathy, and macular edema.
Nearly 60% of the requests remained unresolved after 24 hours, and most requests resulted in a delay of care. Also, staff members needed to spend a median of 100 minutes on each request.
‘Clear, Easy, and Quick’ — but Not Yet
Brian Callaghan, MD, MS, neurologist at University of Michigan Health and professor of neurology at the University of Michigan Medical School in Ann Arbor, Michigan, echoed Dang’s comments.
“Medications are the big issue with PAs, so the fact that this is not addressed means that the changes are much less likely to be meaningful,” said Callaghan, who has studied PA mandates.
“PAs can help prevent unneeded care, but the process needs to be clear, easy, and quick,” he said. “The VA has a great system in place for this type of process, but outside the VA, the process is quite variable, difficult, and slow.”
Neither Callaghan nor Dang has noticed significant reductions in day-to-day PA mandates.
“Administrative teams are still spending hours on the phone,” Dang said. “Until the reduction is large enough and consistent enough across payers, physicians and their teams on the ground won’t feel it.”
What Should Happen Now?
Drevna, the senior director with the American Medical Group Association, called for several PA reforms, including expedited decisions.
“We hear from a lot of our members about patients who are essentially stuck in limbo at a hospital, waiting to get discharged to a post-acute care facility and waiting for prior authorization,” he said. “They’re scheduled to be discharged on a Friday, and they might be there all weekend because they’re waiting for that stuff to come in.”
Drevna said transparency about mandates is also key. “What exactly is it that you’re asking us to provide? What is the clinical evidence that you’re requesting so we don’t get into this back and forth of, ‘Oh, you didn’t fill out Schedule E, or there’s an error here, so we’re going to deny this.’”
He also supported Gold Card-type programs, which essentially say, “Here’s a clinician or a group that has clearly demonstrated that they are prescribing or delivering care appropriately.”
However, a Gold Card program in Texas has had limited impact.
‘Holy Grail’ of Real-Time Electronic Approval
Dang called for government action regarding PA mandates because “voluntary reform has been too slow and too incremental.”
“We need standardized timelines, transparent denial criteria, and real accountability when PA delays cause patient harm,” he said. “At minimum, we need universal adoption of electronic PA, mandatory response time limits, and public reporting of PA denial rates and overturn rates by plan and by service.”
As he explained, real-time electronic PA in particular is a “holy grail.”
It “means I can tell a patient sitting in front of me exactly what treatment plan we’re proceeding with, not guessing what an insurance company will ultimately approve, and then have them call days later with bad news. If insurers deliver on that single commitment, it would do more to fix the PA problem than any percentage reduction in volume.”
Callaghan disclosed having a relationship with the American Academy of Neurology. Dang disclosed having relationships with Eoserna, Genentech, Regeneron, Bausch + Lomb, Amgen, and Retina Consultants of America. Pestaina disclosed having no disclosures.
