Electronic Health Reporter

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.

Only 20% of patients report having a clear understanding of their coverage and costs before receiving care. This lack of clarity fosters mistrust in the healthcare system and puts patients at

risk of unexpected financial burdens. Efforts to standardize and simplify communication between insurers, providers, and patients are critical to addressing these gaps.

Steps Toward a Better System

To create a more equitable and efficient healthcare system, reforms must focus on technology integration, transparency, and policy advancements. Leveraging automation and real-time data-sharing tools can streamline the PA process, enabling faster approvals and reducing the administrative workload on providers.

Proposals like CMS’s emphasis on digital prior authorizations, which promote interoperability across platforms, are an encouraging step toward reducing friction in the system.

Transparency is another critical priority. As the Biden-Harris Administration’s recent Medicare Advantage and Part D proposals suggest4, patient-focused reforms—such as real-time drug pricing tools and simplified cost-sharing models—can significantly enhance the patient experience. Implementing these measures system-wide could help bridge the current gaps in coverage clarity and cost predictability.

By reducing the administrative barriers posed by prior authorizations, industry stakeholders can focus on improving outcomes and fostering trust between patients and providers. Streamlined regulations, such as CMS’s proposed timelines for PA responses, are necessary to create a system that prioritizes patient care without compromising necessary oversight.

Reimagining Patient-Centered Healthcare

The issues surrounding prior authorizations are more than just administrative inefficiencies—they are a barrier to timely, affordable, and equitable care.

While recent policy proposals and technological advancements show promise, meaningful change will require a coordinated effort from all stakeholders in the healthcare ecosystem.

Embracing reforms that prioritize transparency, efficiency, and patient-centered care can transform the PA process from a roadblock into a bridge to better health outcomes. The time for action is now.

When we envision a healthcare system free from the unnecessary hurdles of prior authorizations, we see a future where patients receive the care they need without delay, providers can focus fully on improving health outcomes, and insurers support equitable access.

Achieving this vision will demand bold leadership, innovative solutions, and collaboration across every corner of the industry. Together, we have the opportunity to reimagine a healthcare experience that restores trust, minimizes burdens, and ultimately delivers on the promise of quality care for all.