Facing backlash, health insurers to curb use of prior authorization Image By HPN Staff Key Points U.S. health insurers, under pressure from policymakers, will scale back prior authorization requirements by 2026, easing delays that frustrate patients and doctors. The AMA reports widespread harm from prior authorization, with 93% of doctors saying it delays care and over one-quarter linking it to serious health consequences. At least 10 states have already passed laws limiting prior authorization, while AHIP pledged six reforms, including reducing claims subject to prior authorization and expanding real-time electronic approvals. Amid growing pressure from federal and state policymakers, U.S. health plans are reforming the controversial practice of “prior authorization,” which requires doctors to seek advance approval from an insurance company before performing treatments or prescribing medications. By the start of 2026, U.S. health plans will reduce the number of treatments that are subject to prior authorization, according to America’s Health Insurance Plans (AHIP), the national trade association for the health insurance sector. The move is part of a broader set of reforms, announced in partnership with the Trump administration, designed to reduce delays and remove barriers to treatment that have frustrated patients and health care providers when dealing with insurance companies. “Pitting patients and their doctors against massive companies was not good for anyone,” said U.S. Health and Human Services Robert F. Kennedy, Jr. “We are actively working with industry to make it easier to get prior authorization for common services such as diagnostic imaging, physical therapy and outpatient surgery.” Why it matters According to the American Medical Association (AMA), 93% of doctors blame prior authorization for delaying patient care. More than one quarter of doctors further blame the practice for causing “serious adverse” consequences, including hospitalization, life-threatening events, birth defects and deaths. AMA survey data further shows that the average doctor submits 39 prior authorization requests per week, adding an average of 13 hours or workload per week for physicians and their support staff. Meanwhile, patients are forced to try ineffective treatments and schedule additional office visits due to the hurdles posed by prior authorization policies. “These delays inevitably lead patients to seek more expensive forms of care, including emergency room … visits, and can even lead to unexpected hospitalization,” the AMA has warned. The bigger picture Ironically, instead of reducing costs, prior authorization makes healthcare more expensive, according to a 2021 study by the University of California, Berkeley and Novartis Pharmaceuticals. For prescription drugs alone, the additional cost incurred exceeds $93 billion per year. For this reason, at least 10 states have already passed laws to limit the use of prior authorization in the health insurance sector: Colorado, Maine, Maryland, Illinois, Minnesota, Mississippi, Oklahoma, Vermont, Virginia and Wyoming. Meanwhile, the AMA has developed model legislation for other states to consider. During the Biden administration, federal officials approved prior-authorization reforms in Medicare Advantage, Medicaid, the Children’s Health Insurance Program, and individual insurance coverage purchased through Affordable Care Act marketplaces. More detail Overall, AHIP announced six major actions to be taken over the course of 2026 and 2027: Reducing the number of claims subject to prior authorization Standardizing electronic systems for prior authorization in order to speed up decision times Ensuring at least 80% prior-authorization decisions are made electronically in real time Continuing existing approvals for 90 days when patients change health insurance plans Providing clear and easy-to-understand explanations of prior authorization decisions and how to appeal them Ensuring that all denials of prior authorization are reviewed by medical professionals (a practice that is already in place, according to AHIP)
