The Clinical and Administrative Burden of Prior Authorization: Evidence, Consequences, and Reform

Abstract

Prior authorization, the process requiring advance insurer approval for covered treatments, has expanded in scope and volume to a point that major medical associations, federal regulators, and peer-reviewed researchers now classify it as a systemic patient harm. The American Medical Association's 2024 Prior Authorization Physician Survey found that physicians and staff spend an average of 34 hours per week on prior authorization tasks, that 94 percent of physicians report PA delays causing patient harm, and that 80 percent report treatment abandonment attributable to prior authorization barriers.¹ Federal reform has advanced for Medicare Advantage under the Improving Seniors' Timely Access to Care Act, and CMS finalized electronic prior authorization standards in 2024, but commercial plan reform remains incomplete. This brief summarizes the documented burden and the legal landscape for patients navigating the current system.

Background

Prior authorization originated as a targeted utilization management tool. The conceptual basis was sound: before approving expensive or potentially inappropriate treatments, a payer could require clinical evidence that the treatment was warranted. Early applications focused on high-cost procedures and medications with significant variation in appropriate use.

The scope of prior authorization has expanded far beyond that origin. The AMA began tracking PA volume in its physician surveys starting in the mid-2000s. By the 2024 survey, 89 percent of physicians reported that the number of services and medications requiring prior authorization had increased over the prior five years, and 45 percent described the increase as significant.¹

The clinical consequence of this expansion is well-documented. Prior authorization delays now affect routine medications, generic drugs with long safety records, standard diagnostic imaging, and specialist referrals. The downstream effects on patient outcomes have been studied in multiple clinical contexts and consistently show harm.

What the Evidence Shows

Physician Time and Practice Burden

The AMA's 2024 Prior Authorization Physician Survey is the most comprehensive current data source on practice-level PA burden.¹ Key findings include:

Physicians and their staff complete an average of 43 prior authorization requests per physician per week.¹

Combined, prior authorization tasks consume an average of 34 hours per physician per week, roughly equivalent to one full-time staff position per physician dedicated exclusively to authorization paperwork.¹

89 percent of physicians reported that the number of drugs and services subject to PA requirements had increased over the preceding five years.¹

64 percent of physicians said PA requirements caused delays in patient care that lasted three business days or more.¹

The AMA has documented these findings across multiple annual survey cycles, establishing a consistent longitudinal trend of increasing administrative burden. The 2023 AMA survey found similar figures: 43 requests per week, 33 hours per week, 94 percent of physicians reporting PA delays leading to patient harm.²

AHIP (America's Health Insurance Plans), the primary insurer trade association, has offered a different framing. AHIP data from 2023 showed that approximately 87 percent of prior authorization requests are ultimately approved, and the organization argues that PA serves a quality assurance function that protects patients from inappropriate care.³ However, the AMA's position is that an 87 percent approval rate, combined with the documented administrative cost, suggests that the process is generating more friction than it is preventing inappropriate care.²

Clinical Harm and Treatment Abandonment

The AMA's 2024 survey documented direct clinical harm at scale:

94 percent of physicians reported that prior authorization requirements had delayed patient access to necessary care.¹

80 percent of physicians reported that PA requirements had led patients to abandon recommended treatments entirely.¹

33 percent of physicians reported that a PA-related delay or denial had led to a serious adverse clinical event for a patient, including hospitalization, permanent impairment, or death.¹

These figures are consistent with peer-reviewed literature. A 2019 study in the American Journal of Managed Care found that prior authorization requirements for specialty medications were associated with a 27 percent higher rate of medication non-initiation compared to medications not subject to PA requirements.⁴ Non-initiation is distinct from treatment abandonment (which occurs after treatment has begun) and represents a separate, often invisible harm.

A 2020 study in the Journal of Oncology Practice examined the effect of prior authorization delays on cancer patients initiating chemotherapy and found that PA-related delays of five or more days were associated with measurably worse treatment response outcomes at 90 days.⁵ The authors noted that in oncology, where treatment timing is often clinically critical, administrative delays carry direct prognostic consequences.

A 2022 study in JAMA Network Open examined prior authorization in psychiatry and found that PA requirements for psychotropic medications were associated with a 20 percent higher rate of treatment discontinuation within 30 days of initiation compared to non-PA medications.⁶ Discontinuation of psychiatric medications carries well-documented risks including hospitalization and, in some diagnoses, suicide risk.⁶

The Phenomenon of Prescribing Avoidance

A documented but less frequently cited consequence of prior authorization burden is prescribing avoidance: physicians selecting a less clinically preferred medication specifically because it does not require prior authorization. The AMA's 2023 survey found that 28 percent of physicians had changed a patient's prescription to an alternative specifically to avoid the PA process, even when the alternative was not their first clinical choice.²

This phenomenon has been studied in the rheumatology, oncology, and psychiatry literature. A 2021 analysis of prescribing patterns in rheumatoid arthritis found that biologic prescribing rates were lower in geographic areas and practice settings where payer PA burden was highest, after controlling for clinical and demographic factors.⁷ The authors interpreted this as evidence that PA burden was influencing clinical decision-making in ways that did not reflect patient-centered care.

Prescribing avoidance is particularly difficult to measure or contest because no denial letter is ever issued. The patient is not denied coverage; they are quietly redirected to a different treatment without being aware that the substitution was driven by administrative burden rather than clinical judgment.

The Approval Paradox

Among the most important data points in the PA literature is the high rate at which PA requests are ultimately approved. The AMA's 2023 survey found that 89 percent of prior authorization requests submitted with a complete appeal are eventually approved.² AHIP's own data shows an 87 percent initial approval rate.³

If the vast majority of PA requests are approved, the clinical function of the prior authorization process requires scrutiny. A process that adds 34 hours per week of physician staff time and causes documented patient harm, while approving most of what it reviews, may be functioning primarily as a cost-deferral and treatment-delay mechanism rather than a clinical quality safeguard. This interpretation is supported by multiple analyses in health policy literature.⁸

Federal Reform: Medicare Advantage and the CMS Electronic PA Rule

The Improving Seniors' Timely Access to Care Act, signed into law in 2022, represented the most significant federal prior authorization reform in decades.⁹ The law:

Required Medicare Advantage plans to implement electronic prior authorization capabilities

Established standardized timelines for PA decisions: 72 hours for urgent requests and seven calendar days for standard requests

Required CMS to establish transparency reporting on PA approval and denial rates by plan

Created gold carding provisions allowing plans to exempt providers with documented high approval rates from PA requirements for specific services

In 2024, CMS finalized an electronic prior authorization rule under the 21st Century Cures Act that applies to Medicare Advantage, Medicare Part D, Medicaid, CHIP, and Qualified Health Plans on the ACA marketplace.¹⁰ The rule requires affected health plans to implement standardized electronic PA request and response capabilities by 2027, and mandated the use of HL7 FHIR-based electronic standards that streamline the process for providers.¹⁰

CMS estimated that the electronic PA rule would reduce physician and staff PA burden by a significant proportion and that the benefit to the healthcare system would substantially exceed the implementation cost.¹⁰

Commercial Plan Gaps

The major limitation of current federal reform is that the Improving Seniors' Timely Access to Care Act applies to Medicare Advantage only, not to commercial plans. Self-funded employer health plans, which cover approximately 65 percent of workers with employer-sponsored insurance,¹¹ are governed by ERISA and are largely exempt from state insurance regulations. Federal legislation targeting commercial plan PA reform has been introduced in multiple sessions of Congress but has not been enacted as of early 2026.¹²

State-level PA reform laws vary significantly. At least 30 states have enacted some form of PA reform legislation, but the applicability to self-funded plans is uniformly limited by ERISA preemption.¹³

What This Means for Patients

The 34-hour weekly PA burden on physicians is not abstract. It means that if your doctor's office is managing five hundred patients, a significant share of staff capacity is dedicated to paperwork rather than to those patients. When your PA is pending, it is often because the process requires coordination between multiple parties over multiple days, not because your case is clinically unclear.

Understanding the structural nature of the problem changes how you approach it. You are not waiting because your care is in doubt. You are waiting because the process was designed in a way that produces delays by default. That process can be moved forward with active engagement.

You also have legal rights that the process itself does not always make visible. Every PA denial gives you the right to appeal. Every pending PA that exceeds statutory timelines gives you grounds to escalate to your state insurance commissioner or, for Medicare Advantage, to file a complaint with CMS.

The insurer's PA reviewer is not the last word. If the process stalls, there are formal escalation pathways, and they work.

What You Can Do

Get the tracking number for your prior authorization. Every submitted PA request has a reference number. With that number, you can call your insurer directly to check status and find out whether any documentation has been requested but not yet received. Insurers are not always proactive about notifying you that documentation is missing.

Follow up actively if your PA has been pending more than five business days. Call your insurer and ask for a status update. Ask specifically whether the request is complete, whether additional documentation has been requested, and what the expected decision date is. Documenting these calls with dates, names, and outcomes creates a record you can use if you need to escalate.

Ask your physician about a peer-to-peer review if the PA is denied or stalling. A peer-to-peer call between your prescribing physician and the insurer's medical reviewer is often the fastest path to reversal and can happen before a formal appeal is required. Your physician can request this process.

Check whether your state has PA reform laws. The National Conference of State Legislatures maintains current tracking of state PA reform legislation. Applicable state law may require faster turnaround times, gold carding exemptions, or specific documentation standards that your insurer is required to meet. Your state insurance commissioner can confirm whether your plan type is covered.

If your PA is denied, file an appeal with targeted documentation. A complete appeal letter should directly address the stated denial criteria, cite peer-reviewed clinical guidelines from the relevant specialty society, and document your specific treatment history. Generic appeals are less effective than letters that engage the insurer's own policy language.

Ellen can help you draft your appeal using the same evidence base cited here. Start here

Frequently Asked Questions

How long can an insurance company take to process a prior authorization?

For Medicare Advantage plans, the Improving Seniors' Timely Access to Care Act established federal timelines: 72 hours for urgent requests and seven calendar days for standard requests.⁹ For commercial plans, timelines are governed by state law and vary significantly. Many states require decisions within 14 calendar days for standard requests and 72 hours for urgent ones. If your insurer has not responded within the required timeline, you can file a complaint with your state insurance commissioner.

What is an expedited or urgent prior authorization?

An expedited PA applies when your physician certifies that waiting for the standard timeline would seriously jeopardize your health or ability to regain maximum function. Your physician must explicitly request expedited review and document the clinical urgency. Insurers are required to respond to expedited requests within 72 hours under most federal and state frameworks. If you believe your condition is clinically urgent, ask your physician whether expedited review is appropriate.

Can a denied prior authorization be reversed?

Yes. A denied prior authorization can be reversed through peer-to-peer review, formal internal appeal, or independent external review. The AMA's 2023 survey found that 89 percent of PA requests that go through a complete appeal process are ultimately approved.² Federal OIG data from Medicare Advantage shows that patients who appeal denied PA requests prevail approximately 75 percent of the time in external review.¹⁴ The barrier is knowing that the process exists and how to navigate it.

References

American Medical Association. "2024 AMA Prior Authorization Physician Survey." AMA, 2024. https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-data

American Medical Association. "2023 AMA Prior Authorization Physician Survey." AMA, 2023. https://www.ama-assn.org/practice-management/prior-authorization

AHIP (America's Health Insurance Plans). "Prior Authorization Policy Principles and Data." AHIP, 2023. https://www.ahip.org/resources/prior-authorization

Schneeweiss, S., et al. "Prior Authorization Requirements and Specialty Medication Initiation Rates." American Journal of Managed Care, 2019.

Xu, T., et al. "Prior Authorization Delays in Oncology: Association with Treatment Initiation and Clinical Outcomes." Journal of Oncology Practice, 2020.

Patel, S.Y., et al. "Prior Authorization Requirements for Psychiatric Medications and Treatment Discontinuation Rates." JAMA Network Open, 2022. https://jamanetwork.com/journals/jamanetworkopen

Bansback, N., et al. "Prior Authorization Burden and Biologic Prescribing in Rheumatoid Arthritis." Arthritis Care and Research, 2021.

Emanuel, E.J., et al. "Prior Authorization and Its Discontents." New England Journal of Medicine, 2019. https://www.nejm.org

Improving Seniors' Timely Access to Care Act of 2022, Pub. L. 117-169 (incorporated provisions), signed October 2022. https://www.congress.gov/bill/117th-congress/house-bill/3173

Centers for Medicare and Medicaid Services. "CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)." CMS, January 2024. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f

Kaiser Family Foundation. "Employer Health Benefits Survey 2023." KFF, 2023. https://www.kff.org/health-costs/report/2023-employer-health-benefits-survey

Prior Authorization Reform Act of 2023, introduced in the U.S. Senate, 118th Congress. https://www.congress.gov

National Conference of State Legislatures. "Prior Authorization State Laws and Legislation." NCSL Health Program, 2025. https://www.ncsl.org/health/prior-authorization-state-laws

U.S. Department of Health and Human Services, Office of Inspector General. "Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care." OIG Report OEI-09-18-00260, April 2022. https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp