As prior authorization burden grows, so does momentum for change

Through prior authorization, insurance companies create barriers to treatment—and even the sickest patients aren’t spared from this ordeal.

“Of all the patients and all the conditions that we care for, cancer patients are probably some of the ones for whom the delays and the denials and the claim of ‘that's experimental’ has probably the greatest impact,” AMA President Bruce A. Scott, MD, said while moderating a panel discussion on prior authorization at the 2025 AMA State Advocacy Summit held last month in Carlsbad, California.

Dr. Scott asked panelist Lucy Culp, The Leukemia & Lymphoma Society’s vice president for state government affairs, if prior authorization delays were getting better or worse.

“The evidence is really clear that the prior authorization volume continues to increase,” Culp said.

“When we put the call out to our patients: What are the challenges you're facing with insurance? By and large, prior auth is the first thing we hear,” she said. 

Culp’s organization serves blood cancer patients from across the country, many of whom are seeking financial assistance and help navigating their care.

“Because these are not just incredibly complicated-to-treat diseases, they're extraordinarily expensive to treat, which means that—unless you are Warren Buffet-level wealthy—you are relying on insurance to access your care,” she said.

Culp told of a cancer patient in Wisconsin who was prescribed 12 rounds of chemotherapy by her doctor, and for each one the patient’s health plan required a separate prior authorization.

“That's just one example, and it shows the real challenge patients face and how intrusive their plans are in their overall care decisions,” she said.

Patient advocate Lucy Culp (right) tells Bruce Scott, MD, that complaints about prior auth are what “we hear the most.”

Along with the patient and physician, it’s clear that “there's a third person in the exam room—and it's their insurance company,” Culp said.

Insurance companies’ overuse of prior authorization is causing patients real harm—in some instances even resulting in death. Nearly one-quarter of the 1,000 physicians the AMA surveyed (PDF) in late 2023 reported that prior authorization has led to a serious adverse event for a patient in their care, including 7% who said prior auth led to a patient’s disability or permanent bodily damage, congenital anomaly or birth defect or death.

The AMA is fighting to fix prior authorization by challenging insurance companies to eliminate care delays, patient harms and practice hassles.

Also on the panel was Ron Howrigon, CEO of Fulcrum Strategies, a health care consulting firm specializing in payer-contract negotiation and strategic planning for physician practices. Prior to founding the firm in 2004, Howrigon spent nearly two decades working for some of the country’s largest health insurers.

Howrigon said prior authorization is getting worse and predicted it will continue to worsen in an effort to improve company bottom lines. 

He cited the example of UnitedHealth Group Inc., whose stock sold for $7.50 a share 25 years ago and now sells for $520. And the pressure is on to keep the price climbing upward.

It seems as though payers believe that “the only way to do that is to make things harder” for patients, Howrigon said. “The most egregious stuff are things you can't make up.”

The most recent example of an egregious prior authorization practice came earlier that day, Howrigon said. 

Stay up to date on prior authorization improvements

Get the latest news on the AMA’s fight to eliminate care delays, patient harm and practice hassles.

Subscribe Now

He received an email that morning from a rheumatology group that told him a patient of theirs was denied access to a biosimilar that had been prescribed.

That didn’t concern the physician that much because there is another medication that was very similar to the one prescribed, making it a “Coke-or-Pepsi” level decision, Howrigon said. The problem arose when the physician called the manufacturer and learned that the approved medication would not be available for months. 

Rather than approve the originally prescribed biosimilar, the insurance company replied that this was “a pharmacy problem.”

“No, it's a patient problem,” Howrigon said. “These stories are everywhere. Every single physician I work with has some of these egregious stories about where this thing derails and how it delays and denies the care they want to give to patients.”

Insurers fully or partially denied 3.2 million prior authorization requests in 2023, according to a KFF report. Dr. Scott cited other findings from the report showing that only 11.7% of Medicare Advantage prior authorization denials are appealed—even though 81.7% of those appeals achieved complete or partial success in overturning a decision to deny prescribed care.

State lawmakers are fighting back, as more than 30 states already have introduced legislation this year to reform some part of the prior authorization process, according to the AMA Advocacy Resource Center.

Last year, states enacted 13 prior authorization-reform bills, measures that aimed to cut the volume of prior authorization requirements, reduce patient-care delays, improve transparency on prior authorization rules and boost prior auth data reporting.

Those efforts at the state level build on major 2024 federal regulatory changes to cut care delays and electronically streamline the prior authorization process for physicians treating patients in Medicare Advantage and other health plans regulated by the federal government. Together, the changes will save physician practices an estimated $15 billion over 10 years. 

Legislators need to hear stories like those told by Culp and Howrigon, said T. Christian Miller, a journalist with the nonprofit news organization ProPublica. Last year, Miller wrote about how the Cigna-owned company, EviCore by Evernorth, promised client companies that, for every dollar they paid Evicore, they would pay out $3 fewer in claims.

“They love to deny things,” former AMA president Barbara L. McAneny, MD, says in Miller’s article.

Miller noted that the stories that Culp and Howrigon told have the power to persuade lawmakers and public opinion.

“Those are the stories, the individual pieces, that move mountains—and then you can back that up with data that shows this is not a unique or one-off case,” Miller said. “And that begins to attract the attention of the influencers, the policymakers, who see this as not just an aberration but a pattern.”

Dr. Scott urged the audience to visit the AMA advocacy website, FixPriorAuth.org, to share their stories about how their patients, family members or practices have been harmed by prior authorization.

A majority of the members of the U.S. House of Representatives—135 Democrats and 86 Republicans—did officially co-sponsor the bipartisan Improving Seniors’ Timely Access to Care Act of 2024 (H.R. 8702). But during the lame-duck session, Dr. Scott noted in a statement in December, Congress “missed a golden opportunity to improve patient care by refusing to include prior authorization reform in the final package—a reform with vast bipartisan support in both chambers.”

Learn more with the AMA about the critical changes that must be made to fix prior authorization.