Prior‑auth volume falls
U.S. health insurers say they've cut prior‑authorization transactions by about 11%, eliminating 6.5 million reviews over ten months as they push toward real‑time determinations at point of care. That change arrives alongside a 2024 CMS rule forcing payers to publicly report prior‑authorization metrics and a wave of state reforms—making prior authorization a visible, measurable workflow problem for carriers. (insurancebusinessmag.com) (beckersasc.com) (beckerspayer.com)
A doctor can know exactly which scan or medicine a patient needs and still have to stop and ask an insurer for permission first. This week, major U.S. health plans said they cut that permission step by 11%, which worked out to 6.5 million fewer prior-authorization reviews in 10 months. (ahip.org) Those cuts came from commitments insurers announced in June 2025 across commercial coverage, Medicare Advantage, and managed Medicaid plans serving about 257 million people. The latest update says the biggest drop so far was in Medicare Advantage, where prior authorizations fell 15%. (beckershospitalreview.com) (fiercehealthcare.com) Prior authorization is the paperwork checkpoint insurers use before paying for some drugs, scans, surgeries, or rehab stays. The American Medical Association says 94% of physicians reported care delays tied to prior authorization in its 2024 survey, and 29% said it had led to a serious adverse event for a patient in their care. (ama-assn.org) The industry is not just removing reviews; it is trying to speed up the ones that remain. AHIP and the Blue Cross Blue Shield Association said plans are building toward real-time responses for most electronic prior authorizations by January 1, 2027, so an answer can come while the patient is still in the exam room. (bcbs.com) (insurancebusinessmag.com) Washington pushed this issue into the open in 2024. The Centers for Medicare & Medicaid Services finalized a rule on January 17, 2024 that requires Medicare Advantage plans, Medicaid and Children’s Health Insurance Program managed care plans, and federally facilitated Affordable Care Act exchange issuers to send decisions faster and publicly report prior-authorization metrics. (cms.gov) (federalregister.gov) That rule set two clocks that matter to patients and doctors. Payers covered by the rule must send decisions within 72 hours for urgent requests and within 7 calendar days for standard requests, and they must give a specific reason when they deny something. (cms.gov) (federalregister.gov) States are tightening the screws too, and they are doing it in different ways. Becker’s reported this week that Virginia, Washington, Oregon, Illinois, and Arizona have all enacted 2026 changes, with Virginia’s new law requiring approvals to last at least 6 months for initial requests and 12 months for continuing requests in many cases. (beckerspayer.com) That mix of federal reporting rules and state laws changes the incentives for insurers. Prior authorization used to be mostly a back-office fight between a doctor’s office and a plan, but now denial rates, turnaround times, and approval rules are becoming visible enough to compare across carriers. (cms.gov) (beckersasc.com) The awkward part is that insurers still defend prior authorization as a cost-control tool, especially for expensive or low-value care. AHIP’s own statement called it a safeguard for safe, effective, evidence-based, and affordable treatment even as plans said they were removing millions of reviews. (ahip.org) So the shift is not “no more prior authorization.” The shift is toward fewer requirements, longer-lasting approvals, electronic submissions, and faster yes-or-no answers, with 2027 now set as the industry’s date for real-time decisions on most electronic requests. (bcbs.com) (insurancebusinessmag.com)
