Prior authorization is a friction point. Here’s how to solve it.

Prior authorization — the process by which insurers review and approve or deny treatments prescribed by doctors — has become “the only piece of healthcare that every single stakeholder, including payers and insurance companies, agrees is broken and needs to be reformed,” Jason Borschow, CEO of Abarca Health, said.

The killing of UnitedHealthcare CEO Brian Thompson in December 2024, Borschow said, was a wake-up call for the healthcare industry. “I don't think the insurance companies realized how deeply the American people were fed up,” Boschow said in an interview. “People think [of prior authorization] as life and death — not just an inconvenience.”

Patients often wait days or weeks for decisions on them, and many are left with uncertainty at the moments they are most vulnerable. According to the American Medical Association (AMA), 94% of patients experience delays in care and 78% abandon treatment altogether. These delays in care are often for lifesaving treatments and can result in adverse events.

A just-released study by NYU Langone Health researchers found that prior authorization may hinder access to life-saving heart failure medications. The analysis focused on angiotensin receptor-neprilysin inhibitors (Entresto) and sodium-glucose cotransporter-2 (SGLT2) inhibitors, such as Jardiance and Farxiga.

People with heart failure whose prescriptions required prior authorization took three times as long to fill an ARNI prescription and six times as long to fill an SGLT2 inhibitor prescription than those whose prescriptions did not require it, the NYU Langone Health study found. Patients whose SGLT2 prescriptions required prior authorization were twice as likely to never fill them.

“While these policies are meant to control healthcare costs by steering patients toward lower-priced alternatives, they may instead be keeping people with heart failure from timely access to lifesaving treatments,” lead author and cardiologist Amrita Mukhopadhyay, M.D., said in a news release. Mukhopadhyay is the Eugene Braunwald, M.D., assistant professor of cardiology in NYU Grossman School of Medicine’s Department of Medicine.

For doctors, prior authorization consumes an enormous amount of resources. Doctors' offices dedicate entire staff workflows to navigating the approval process. An AMA survey released in 2025 of 1,000 physicians found that practices on average have 39 prior authorization requests per physician per week and spend about 13 hours completing these requests each week.

Health plans have been facing significant and very public pressure around their policies on the utilization management tactic that they say is necessary to ensure their members’ care is safe, effective, evidence-based, and affordable.

Plans have vowed to make changes. Last year, more than 50 insurers pledged to streamline and simplify the prior authorization process through six new commitments. But some healthcare leaders and organizations doubt there will be meaningful change. Leaders from the AMA pointed to similar commitments made in 2018 to reduce the volume of prior authorization requirements, improving transparency and automating the process. But that effort didn’t lead to changes in prior authorization, the AMA said.

This is why in January of this year Congress grilled health plans about prior authorization and claims denials. Members of Congress pointed out that in 2023, Medicare Advantage data showed that insurers partially or fully denied 3.2 million prior authorization requests, reflecting 6.4% of total healthcare claims for the year.

At this year’s Abarca Forward, an annual meeting of pharmacy benefit leaders, participants adopted a framework for reforming the prior authorization process. Executives representing health plans, providers, pharmacies, manufacturers, technology companies, employers, and policy stakeholders defined the principles that would be needed. They agreed to a five-point framework that addressed the role of AI and the CMS interoperability. Automation and generative AI can take friction out of the system around administrative tasks.

A mindset shift is needed

Most importantly, there is a need for alignment on utilization management and prior authorization, Boschow said. “The big takeaway from the conference is that the money, the conviction and the technology are already there [for prior authorization]. All that’s missing is the trust and the alignment between the stakeholders. People aren’t realizing that this is not a problem that can be solved independently, and it’s not a problem that needs to be solved by the government.”

Prior authorization decisions, he said, need to be fast and need to be explainable in language that patients and providers can readily and easily understand. “That’s missing from the system. At the end of the day, we’re all patients.”

A second takeaway from Abarca Forward, Boschow said, is that there is a need for integrated data and a centralized source of information. “The future of prior authorization is not so much the interoperability of the data but a better workflow for the exchange of data that can lead to decision-making. It's really about having the data in real time when you need to make these decisions.”

A utilization management system that works for everyone will require a deeper collaboration between payers, providers, technology providers and the government, requiring behavioral change among all stakeholders. Additionally, stakeholders have to understand the need for exchanging data and openly collaborating on standards and models.

“Everyone’s so focused on mandates and proprietary systems and products trying to generate a competitive advantage,” Borschow said. “This is not an area where we should be focused on competitive advantage. This is about making the healthcare system better for everyone.”

Although attendees at Abarca Forward — which included leaders from PBMs, health plans, technology companies and employers — understood the need for a mindset shift, Boschow is cautiously optimistic about alignment across the broader healthcare ecosystem. “The 'aha' moments [at Abarca Forward] were when providers, payers and the technology folks realized they are actually much more aligned and willing to work together. Even this conversation can create the momentum to move this forward. We don’t have to change everything overnight to have a huge impact.”