Jan 5
2025
The Hidden Toll of Prior Authorization Challenges on Healthcare Access
By Andrew Mignatti, co-founder and CEO, Careviso.
Healthcare access in the United States remains fraught with barriers, none as pervasive as the issues surrounding prior authorizations (PAs). Originally designed as a mechanism to ensure that care is both necessary and cost-efficient, PAs have become one of the largest obstacles to timely and affordable healthcare.
A recent survey revealed that over 80% of patients have delayed or foregone necessary procedures, lab work, or medications due to confusion or frustration over PA processes. These numbers highlight an urgent call to address systemic inefficiencies.
This is not just a patient problem—it is a systemic issue with implications for providers and the broader healthcare ecosystem. As healthcare policies evolve, including recent Medicare Advantage proposals from the Centers for Medicare & Medicaid Services (CMS), the need to streamline PA processes and enhance transparency becomes increasingly urgent.
CMS’s proposed changes, aimed at tightening rules around PAs, reflect a growing recognition of their role in impeding care. One proposal calls for Medicare Advantage plans to respond to routine PAs within seven days and urgent cases within 72 hours, a move intended to reduce patient wait times and administrative burdens.
However, challenges persist as stakeholders navigate the complexities of balancing oversight with access.
The Tangled Web of Prior Authorization
Survey data underscores the widespread impact of PA inefficiencies. More than half of patients experience delays in care, with over 40% waiting one to two weeks or more for authorization approvals1. For conditions requiring timely interventions, such delays can lead to deteriorating health outcomes, increased stress, and higher long-term costs for patients and payors alike. Financial burdens further compound these delays, with nearly 40% of patients reporting paying out-of-pocket because of denials or unclear coverage details.
The administrative toll on providers is equally staggering. Navigating PA requirements drains time and resources that could otherwise be directed toward patient care. The recent CMS proposals highlight this strain, as Medicare Advantage enrollees now make up over half of all Medicare beneficiaries. Administrative overhead for these plans often includes increased scrutiny of claims, leaving providers overwhelmed with inconsistent policies and requirements.