For patients and providers alike, prior authorization remains one of the most persistent pain points in healthcare. A recent Kaiser Family Foundation poll found that most patients struggle to navigate the process, and many delay or forgo care altogether. Clinicians say the administrative burden is not only draining but financially unsustainable, as providers absorb rising costs tied to staff hours, inconsistent documentation requirements, and repeated submissions for a single treatment.
In response to mounting frustration, both policymakers and industry leaders are touting reform. According to MultiState, nearly half of US states have introduced legislation over the past year to make prior authorization more transparent and predictable. Many of these laws would require human clinical review of denials, faster turnaround times, and “gold card” exemptions for providers with strong approval histories. On paper, these changes could meaningfully reduce delays and paperwork.
Yet skepticism remains over whether insurers will follow through. Even as payers pledge to modernize their systems, adoption of reforms has often lagged. Efforts to standardize criteria or expand electronic prior authorization (ePA) remain uneven, and implementation timelines stretch across years. And at the same time, many plans are outsourcing larger segments of utilization management to third-party administrators (TPAs) for specific services, creating yet another layer of review that further complicates and slows approvals. Provider groups caution that without consistent enforcement, reforms risk becoming minor improvements rather than systemic change.
However, some promising signs are emerging; Johns Hopkins University recently convened payers, providers, and technology experts to build consensus on automation and transparency, while pharmacy and medical leaders continue to push for real-time ePA tools. Still, questions linger about how quickly plans will embrace these shifts or find new tools that delay care.
Ultimately, meaningful progress will depend on whether insurers are willing to relinquish some control in favor of patient-centered efficiency. Policymakers may have set the stage, but only sustained oversight will turn reform goals into real-world results.