Prior auth metrics go public
A new CMS reporting rule now forces many payers to publish prior‑authorization metrics, making a long‑hidden administrative burden measurable, and five states are moving to reform prior‑authorization rules in 2026. That transparency raises expectations for clinics to track and help patients through upstream delays and to connect referral tracking with actual referral completion ( ).
For years, prior authorization worked like a locked back office in health insurance: doctors sent requests in, patients waited, and almost nobody outside the insurer could see the approval rate, denial rate, or response time. Starting in 2026, many insurers now have to post those numbers on public websites for the first time. (cms.gov) The federal rule comes from the Centers for Medicare & Medicaid Services, which finalized it on January 17, 2024, and set 2026 as the start of public reporting for prior authorization metrics from the previous calendar year. The insurers covered include Medicare Advantage, Medicaid and Children’s Health Insurance Program plans, and Qualified Health Plan issuers on the federally facilitated exchanges. (cms.gov, cms.gov) What has to go public is not a vague summary. The Centers for Medicare & Medicaid Services template tells plans to post the list of services that require prior authorization, plus approval percentages, denial percentages, appeal overturn rates, and average and median response times for standard and expedited requests. (cms.gov) The same federal rule also put clocks on some decisions. The Centers for Medicare & Medicaid Services said impacted payers must send decisions within 72 hours for urgent requests and seven calendar days for standard requests for medical items and services. (cms.gov) That new visibility lands on top of a workload doctors were already describing as relentless. An American Medical Association survey cited by Becker’s says the average medical practice handled 39 prior authorizations per physician per week in 2024, with physicians and staff spending about 13 hours a week on the paperwork. (beckersasc.com) The same Becker’s roundup says 31% of physicians said prior authorizations are often or always denied, and 3 in 4 said denials have increased somewhat or significantly over the last five years. Nearly 9 in 10 said the process somewhat or significantly increases burnout. (beckersasc.com) Even when a denial looks wrong, many practices do not fight every one. Becker’s reports that only 20% of physicians said they always appeal an adverse prior authorization decision, while about two-thirds said they skip appeals if they think the appeal will fail and more than half said they skip them because they lack time or staff. (beckersasc.com) The numbers get starker in Medicare Advantage, where Becker’s says insurers fully or partially denied 4.1 million prior authorization requests in 2024, or 7.7% of the total. More than 8 in 10 appealed denials were later overturned, which means a large share of “no” decisions did not survive a second look. (beckersasc.com) States are now piling on their own rules in 2026 instead of waiting for federal systems work to spread. Becker’s reports that Virginia, Washington, North Dakota, Nebraska, and Alaska have all rolled out prior authorization changes this year. (beckerspayer.com) Those state laws are aimed at specific choke points. Virginia set minimum approval durations of at least six months for initial requests and 12 months for continued requests, Washington said artificial intelligence can approve but not deny without health professional review, and North Dakota and Nebraska tied nonurgent decisions to seven days and urgent decisions to 72 hours, with automatic approval after the deadline in North Dakota. Alaska now requires notice to patients within 72 hours for routine cases or 24 hours for expedited ones. (beckerspayer.com) The federal data will not solve the whole problem by itself. Becker’s says KFF had trouble pulling deep insights from the first public reports because the data was aggregated and not broken out by service type, and payers did not have to publish the reasons behind decisions. (beckerspayer.com) But once denial rates and response times are public, clinics can no longer treat prior authorization as an invisible handoff that disappears after a referral order. A referral that sits waiting on insurer approval is not a completed referral, and the new public metrics make that gap easier for patients, regulators, and employers to see. (cms.gov, beckerspayer.com)
