Prior authorization has been around for a long time. The goal was originally designed in the 1960s to control costs and ensure proper use of medical resources, with the goal of preventing unnecessary procedures and curbing wasteful spending. But the reality is that previous mandates have evolved into administrative quagmire, delaying care and thwarting doctors. A survey found that 94% of doctors believed that previous authorizations would lead to delayed care, while 89% said this would have a negative impact on clinical outcomes.
A simple fact is that modern forms of prior authorization are barriers to efficiency and optimization of care quality – our industry is facing the moral power to fix it. No one can do this alone. It is becoming increasingly clear that previous authorization reforms are a collective responsibility that requires support from public and private entities in the healthcare ecosystem.
An unstoppable administrative burden
In the face of medical advances, new treatments and increased costs, insurance companies initially use prior authorization as a gatekeeper. Over time, PA has expanded in almost every aspect of patient care – medications, diagnostic imaging, surgery, and inexplicably, even routine treatments. This creates a huge administrative burden. According to the latest report from the Affordable Quality Health Care Commission, the healthcare industry spent $1.3 billion on PA-related administrative expenses in 2023.
It becomes untenable. Now, physicians spend an average of 13 hours a week to navigate PA barriers. It’s time for doctors to use to treat patients, but they’re trapped in dealing with the traditional Chinese tape. Although PA is designed by an insurance company to reduce costs, how to solve it? Administrative waste has been one of many factors driving health care spending, as well as downstream costs of untreated or poorly managed conditions. Long time ago, it was no longer inconvenience: it gradually graduated from the public health crisis caused by systemic friction. Reform is essential, but how we reform will determine whether we solve the problem or simply add new layers of complexity.
The roadmap for responsible reform: Going beyond the status quo
To effectively address previous empowerment crises, we need a comprehensive approach to balancing legitimate cost issues with patient care and provider efficiency. I propose a four-part roadmap to change prior authorization. It won’t solve all the problems with today’s PA process, but at least it will take us in the right direction.
The first step is to increase transparency of previous authorization rules and metrics. Current PA standards are often opaque, inconsistent, and difficult for providers to navigate. Payers are requested to issue clear, standardized guidelines for medical necessity, updated monthly so that patients and providers know exactly what they need. Guessing is the enemy of efficiency.
Additionally, a public payer scorecard should be issued monthly to show submission approval rate, turnover time and appeal rate. Data must also be provided through open APIs to ensure seamless integration into provider workflows and minimize administrative burdens. The industry is making some progress: Medicare & Medicaid Service Center has passed the final rules that simplify the previous authorization process in 2024, but private business leaders must now strengthen their reforms. Based on existing CMS frameworks, they need to comply with the same standards.
The second step is to eliminate the gold medal. I understand the appeal of exemptions to exempt trusted parties with a good track record in PA requirements. On the surface, the gold card sounds like a good solution. Logical track. However, this practice opens up a brand new can of worms, forcing providers to track different rules for different insurers. By creating another layer of complexity, the gold medal actually undermines the goal of reducing administrative friction and perpetuating it. Instead of choosing which providers are exempt based on criteria determined by insurance providers, payers need to unite to develop and adopt common policies and standards that apply to all providers, with a focus on fair and transparent rules. The easiest way to eliminate gold medals is to make them obsolete.
Next is the reform of regulations. The current situation is a mess, a patchwork of regulations that make changes between states. This is a must-we need to replace state-level regulations with a unified federal policy that applies to all. If you don’t believe me, just ask someone who complies with the national health system or insurance company: Prior authorization regulations are a nightmare filled with traditional Chinese tape festivals and conflict requirements. It is slowing us down and affecting the quality of care patients receive.
Will it be easy to create a single federal standard to ensure transparency, timeliness and patient safety? You can pick up any newspaper and prepare questions about Congressional dysfunction to answer this question. This will require real effort, but it is a bipartisan issue and the end result will be worth it: simplified operations, lower compliance costs, and most importantly, ensuring patients receive consistent treatment regardless of where they live.
The final step: We have to bring doctors into the cycle through technical integration. Interoperability between electronic medical records (EMRS) is a fundamental requirement for effective PA, but is currently insufficient. API access must be free and universal to ensure that all providers can integrate pre-authorized data directly into their workflows to reduce friction. As an additional bonus, this allows doctors to focus on patient care rather than paperwork.
Prior authorization reform is no longer an abstract policy debate. This is a necessary condition for patient safety, physician well-being and system-wide efficiency. We can’t wait for the perfect solution. Today, these tools exist that can significantly reduce the burden on our healthcare system by PA, and we just need to mobilize and implement them.
Collective needs to start: It’s time for doctors, insurers and policy makers to stop tolerating problems and start solving them. Our patients and our healthcare workers have been patiently waiting for solutions, but their tolerance is thin and deserves better choices. Now is the time to act.
Photo: SQBACK, Getty Images
Dr. Jeremy Friese is the transformative force at the intersection of healthcare delivery, AI innovation and payer strategies. As founder, chairman and CEO of Humata Health, he leads the development of advanced AI solutions that simplify previous authorizations to address one of the most challenging friction points for healthcare for providers, payers and patients.
Before Humata Health, Jeremy pioneered AI-driven solutions for health systems and health programs. His latest adventure was acquired through Avairity and serves as the backbone of its previously authorized automation platform. During the last two decades at Mayo Clinic, Dr. Friese is both an interventional radiologist and a global business development leader, and has launched a strategic partnership to expand Mayo’s innovative care model to serve more than 20 million patients worldwide. He helps his approach to healthcare transformation with his experience in bridging clinical practice with his operational efficiency.
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