By Mark Craig
When Jin’s mother experienced respiratory and heart failure, she got a tracheostomy and spent two weeks in the ICU, relying on a ventilator to breathe. When she was finally stabilized, the family received the good news that she could be transferred to a long term acute care (LTAC) facility to be weaned off the ventilator for the next stage of recovery.
According to Jin, the insurance company, Aetna, had other ideas. They took five days to deny the prior authorization request for LTAC admission, without providing any explanation for the denial. When the ICU team requested a peer-to-peer clinical review, Jin says Aetna told them it was too late for that, and all they could do was appeal. Jin’s family proceeded with the appeal, but Aetna declined again, and the family was out of options. The ICU doctors told Jin they see this happen regularly, and that many patients have no choice but to give up and resort to hospice care.
Why would a patient with a clear path to recovery be denied the care they need?
The answer, increasingly, is prior authorization (PA)—an intentionally complex bureaucratic process that gives insurance companies blanket power to overrule your doctor and delay or deny your care, all while posting mind-boggling profits year after year.
Prior authorization started as a reasonable cost-containment measure sixty years ago, applied sparingly to only the most expensive treatments. Today, it has become a sprawling corporate apparatus. It’s been progressively expanded, automated, and systematically engineered by insurance companies over the decades to find reasons to delay care or refuse payment. And now, it’s deployed at scale by AI, often without any human review at all.
The outcomes are truly devastating to patients. Ninety-five percent of physicians say that PA delays access to necessary care, and 26 percent report that PA requirements have led to a serious adverse patient event including hospitalization, permanent impairment, and death.
These are treatments and medications that qualified doctors believe are necessary, and they’re being overridden by insurance companies.
One patient, Andrea, says, “I was injured in a vehicle accident resulting in debilitating migraines and head, neck, and facial pain from a brain injury. I suffered two years of headaches to ‘fail’ enough treatments for insurance to approve a five-year-old treatment that’s now gold standard for migraine relief.”
Another patient, Ocean, woke up one day with blurry vision and was referred to a specialist. The referral was blocked by her insurance company. Twelve weeks later, she finally received authorization to visit the neuro-ophthalmologist, but by then, it was too late; Ocean was blind.
It isn’t just patients who suffer. The impact of prior authorization on physicians and their staff is truly staggering.
Physicians complete 40 PA requests each week, which takes an average of 13 hours—almost two full working days. Forty percent of physicians have staff who work exclusively on PA.
“We have four full-time employees whose sole focus is on obtaining prior authorization for medications to treat Crohn’s disease and ulcerative colitis—and that’s just for one disease state,” says Dr. Jessica Korman, a gastroenterologist.
And when a PA is denied, the physician’s only recourse is peer-to-peer review, a process that sounds reasonable in theory, but is designed to fail in practice.
The premise is straightforward: A treating physician gets on the phone with a clinical peer at the insurance company to make the case for why their patient needs the prescribed treatment. But the “peer” in peer-to-peer is itself a fiction. Only 16 percent of physicians say the insurer’s reviewer typically has the right qualifications or is a true “peer.”
More often, a pediatrician argues with a neurologist at the other end of the line. Dermatologists are overruled by OB-GYNs. Specialists in rare diseases speak to reviewers who can’t pronounce the name of the drug in question. Many so-called peers aren’t even physicians at all.
Dr. Alexa Kimball knows this all too well. As president and CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, a Harvard professor with more than 385 published articles, and the physician who developed three FDA-approved medications for a debilitating rare skin disease, she is about as credentialed as a physician gets.
To insurance companies, that doesn’t matter. When an insurer denied coverage for a promising treatment for one of her long-term patients, Dr. Kimball initiated a peer-to-peer review. After weeks of waiting, her office received a call on a Thursday afternoon saying that Dr. Kimball herself needed to return the call. She did so as soon as possible, two and a half hours later, and reached what appeared to be a personal cellphone voicemail. She left a careful message, uncertain she had even dialed the right number.
The next morning, the case was closed by the insurer. The peer had marked it unresolved, with no callback and no avenue to escalate. Because insurers often rely on third-party companies to conduct these reviews, Dr. Kimball still doesn’t know who the reviewer worked for or whether they had any relevant qualifications at all.
“The peer-to-peer review process often feels like a black box,” Dr. Kimball says, noting that insurers “use this structural barrier as a way to delay or deny care.”
The endless bureaucratic red tape, the delays, and the denials caused by pervasive prior authorization have gotten so bad that it’s driving physicians out of the practice of medicine.
“If you’re thinking about what allures you to medicine, no one ever says, ‘I’m really excited about going to work and arguing with insurance companies about a prior authorization,’” says Dr. Amir Barzin, a family medicine physician and COO at UNC Health.
As frustrating and time consuming as PA requirements are for physicians, the even more problematic result is moral injury, which “describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to a variety of constraints that are beyond [physicians’] control.”
According to a survey of over 1200 physicians conducted by Physicians for a National Health Plan, 50 percent of doctors feel “betrayed by a healthcare system that hinders their ability to provide good patient care.” Sixty-eight percent reported experiencing moderate or severe distress as a result of their inability to provide patients with the best possible care.
“The burnout comes from the moral injury of having a process, like pre-authorization, that now takes away the physician’s autonomy in making those decisions,” says Dr. Gary Price, president of the Physicians Foundation. “But it doesn’t take away the responsibility. That is a tremendous moral injury that goes on day by day, almost like paper cuts, as your ability to care for patients is constantly being impeded by these barriers.”
Moral injury is accelerating an exodus of doctors that the healthcare system can ill afford.The United States faces a shortage of up to 86,000 physicians by 2036, along with a nursing workforce shortage of nearly 109,000 by 2038.
“The physician shortage is already having serious implications for patients and medicine as a whole,” notes Dr. Marilyn Heine, a member of the AMA Board of Trustees and clinical assistant professor in the Department of Medicine at Drexel University College of Medicine. She says physicians are “cutting back on their hours, changing their practice, or retiring early, often because of administrative burdens which are largely driven by prior authorization.”
Dr. Heine continues, “This is a major concern. Unless urgent action is taken to address these burdens, the physician shortage is going to get worse. That means longer wait times for patients, less access to high-quality physician-led care, and ultimately, worse outcomes for patients.”
Insurers justify prior authorization by saying it prevents unnecessary care, protects patients from treatments that aren’t clinically proven, and controls costs.
In the first place, doctors are in a better position to determine the care their patients need; it’s ridiculous on its face to pretend insurers must protect patients from their physicians’ treatments.
“I am a board-certified gastroenterologist,” Dr. Korman says. “I know what I’m doing—only to be blockaded by all of this bureaucracy and red tape.”
Secondly, PA does not control costs. In fact, it inflates them. When care is delayed or denied, patients don’t simply get better on their own; diseases progress and conditions worsen. Nearly 90 percent of physicians say prior authorization leads to higher overall utilization of healthcare resources. This includes more emergency visits, more hospitalizations, and more downstream costs that dwarf whatever the insurer saved by denying the original request.
The only ones benefiting from prior authorization are the insurance companies, and the numbers speak for themselves. In 2025, the seven largest for-profit health insurers booked more than $54 billion in profits on nearly $1.7 trillion in revenue. That’s a 300 percent increase since 2015, nearly five times the revenue growth of the broader S&P 500 over the same period.
Prior authorization isn’t the only driver of those profits, of course. But it plays a significant role, which is exactly why it continues to spread.
PA gives insurers a mechanism to delay or avoid paying out on patient premiums for as long as possible—and in many cases, permanently. The more claims they deny, and the more patients who give up without appealing, the more money stays in their pocket.
When faced with a prior authorization denial, 79 percent of patients give up pursuing treatment. That means that the premium dollars that should have gone to patients’ doctor-recommended care goes instead to shareholders—primarily massive institutional investors like BlackRock, Vanguard, and Morgan Stanley. It also goes to acquiring physician practices, clinics, and pharmacy operations, allowing insurers to collect premiums on one end and own the care delivery on the other. And it sits in investment accounts and real estate holdings, compounding daily while patients forgo treatment, and in some cases, die waiting.
Here is the simple proof that PA is a financial strategy as opposed to a clinical safeguard: According to a 2024 KFF analysis of Medicare Advantage insurers (who operate the most aggressive prior authorization programs in the industry) 81 percent of denials that were appealed, were overturned. Based on their own data, insurers are denying large volumes of medically necessary care, betting that most patients and providers won’t have the time, energy, or resources to fight back.
Dr. Archelle Georgiou, a former Chief Medical Officer at UnitedHealthcare who analyzed federal PA disclosure data earlier this year, puts it this way: “The friction is not a flaw in the system. It is the strategy.”
Insurers have made a series of promises to reform PA, dating back to 2018; but it should be no surprise that so far, none of them have panned out.
The most recent was the 2025 “voluntary pledge” taken by over 60 commercial insurers to reduce PA burdens. It was announced with much fanfare and made many headlines, but it’s hard to imagine that people are still falling for this kind of reform theatre.
Shortly after the pledge was announced, AHIP—the health insurance industry’s own trade group—issued an article claiming participating plans had reduced prior authorizations by 11 percent. But as Dr. Georgiou points out: “Reduced relative to what? The denominator matters enormously.” She couldn’t locate the survey methodology or the underlying data behind the headline. Just the number, floating there, unverifiable, issued by the industry about itself.
Like all flimsy insurer promises of PA reform, there is no enforcement mechanism on this pledge, no independent oversight, and no consequences for non-compliance.
The real solution is simple and proven. Go back to the old days of prior authorization, when it functioned as a rarely used, reasonable check and not as a back door for massive insurer profits.
SCAN Health Plan, a nonprofit Medicare Advantage insurer operating across five states, has been using prior authorization in exactly this way since 1977. They apply it as a narrow exception, used sparingly, with a presumption that physicians know what they’re doing. They intervene only when there is documented evidence of a problem—fraud, proven overprescribing, genuinely experimental treatment—not as a blanket cost-control mechanism applied to chemotherapy and heartburn medication alike. Because SCAN is organized around care delivery rather than maximizing quarterly shareholder returns, it has little incentive to weaponize prior authorization. Their approval rate is 98 percent, outcomes are good, costs are managed, and the sky has not fallen.
And we can look to Traditional Medicare, the federal program covering nearly 68 million Americans, as another example. Medicare processes fewer than 400,000 prior authorization requests annually, compared to nearly 53 million in private Medicare Advantage plans. Traditional Medicare covers the same patient population, the same services, and costs taxpayers 22 percent less. Put another way, the program that uses prior authorization least is also the program that costs least.
But even Traditional Medicare is falling prey to prior authorization schemes that benefit private corporations, as I wrote about last year. Under Dr. Mehmet Oz, CMS instituted their so-called WISeR model in January 2026, which uses AI-powered PA for a select set of procedures and lays the groundwork for more. We’re just a few months in, and the results are discouraging, but not surprising: delays, denials, communication breakdowns, and patients waiting in pain.
At his confirmation hearing for CMS Director in March 2025, Dr. Oz himself offered some reasonable PA reforms. He suggested limiting PA to only 1000 procedures and treatments, and said that approval should be as fast as a credit card transaction, where “you know immediately whether [it’s] approved or not.” Over a year later, we are no closer to those goals.
The health insurance industry has built a massive apparatus of lobbyists, public relations teams, and propaganda groups, all designed to keep serving their own best interests. They donate heavily to political campaigns on both sides of the aisle. As with all major reforms, change is going to have to start with the American people.
What can we do? For one, challenge your own prior authorization denials. As mentioned, 79% of patients give up when faced with a denial, but when they do challenge it, it’s overturned 80% of the time. KFF offers a helpful list of tips for taking the initiative on appeals instead of relying fully on our doctors to take care of it. If even a fraction of patients fight back, the financial model that depends on patient surrender starts to break down. The tipping point comes when we start costing insurers more than they make from our acquiescence.
Beyond that, PA is a political problem that requires political pressure. Tell your representatives to support the Improving Seniors’ Timely Access to Care Act, which would force faster decisions and real transparency from insurers. While it’s focused only on Medicare Advantage, the bill is gaining real traction and is a good place to start.
Ultimately, there’s a more fundamental fix than any single bill. Insurers have constructed monopolies designed to extract money at every turn. UnitedHealth, for example, is the nation’s largest insurer and largest physician employer. They operate one of three dominant pharmacy benefit managers, run the country’s largest claims clearinghouse, and even own a bank. They control who provides your care, who pays for it, who processes the claim, and who finances your debt.
A growing coalition is pushing for a Glass-Steagall-style breakup of these vertically integrated giants, which would structurally separate insurers from the physician practices, pharmacies, and PBMs they own. Prior authorization is just one symptom of the overall conflict of interest; breaking up vertical integration addresses the disease. It may sound like a long shot, but that’s only because the status quo has gone unquestioned for so long.
The tragedy of prior authorization is that it succeeds as intended. Every delayed treatment, every abandoned appeal, every patient who gives up is evidence that the system is functioning precisely as the insurers have designed it. Until that incentive structure changes, the suffering will continue.
About Mark Craig
Mark has spent over two decades in the financial trenches of healthcare, helping providers recover revenue that insurers work hard to deny, delay, and underpay. As founder and CEO of Write-Off Warrior, he has built a reputation for deep policy analysis, insightful original research, and tenacious advocacy.
Mark is the creator and lead researcher for Preyed On: How Insurance Corporations Are Exploiting America’s Hospitals, an ongoing nationwide survey of healthcare leaders sharing their struggles and solutions for payer abuse, particularly Medicare Advantage plans. He has contributed to healthcare research with Johns Hopkins University and is a regular speaker at healthcare conferences. He regularly collaborates with lawmakers and advocacy groups to advance targeted oversight reforms that expose and dismantle predatory insurer practices.
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