Prior Authorization: When Getting Approval Becomes a Barrier to Getting Care

Most people do not think about prior authorization until they are stuck waiting for it.

A doctor recommends a medication, procedure, test, device, or treatment. The patient is ready to move forward. The provider is ready to deliver care. But before that care can happen, the health plan may require one more step: approval.

That step is called prior authorization.

In theory, prior authorization is meant to confirm that care is medically necessary, appropriate, and covered by a patient’s health plan. It can be used as a tool to manage costs, avoid unnecessary care, and encourage evidence-based treatment.

But in real life, prior authorization can become something else entirely. It can become a delay. It can become a denial. It can become a stack of forms, phone calls, portals, appeals, and confusion. And for patients who are already trying to navigate a complicated healthcare system, that delay can feel like the system is asking them to prove they deserve the care their clinician already said they need.

That is why prior authorization has become one of the most important healthcare access issues of this moment.

Across the country, patients, physicians, advocates, policymakers, and even insurers are acknowledging that the current process is not working the way it should. It is too often slow, inconsistent, opaque, and burdensome. When approvals are delayed, patients may wait longer for diagnostic tests, specialty care, procedures, medications, or treatment plans. Some may give up altogether. Others may get sicker while waiting.

For Black women and our families, this issue deserves special attention.

Black women already face too many barriers to timely, respectful, affordable, high-quality care. We are more likely to have our symptoms dismissed, more likely to experience delays in diagnosis, and more likely to carry the weight of a healthcare system that was not designed with our full humanity at the center. When prior authorization adds another hurdle, it does not land in a neutral system. It lands in a system already shaped by inequity.

A delayed approval can mean delayed pain relief.

A delayed diagnostic test can mean a delayed diagnosis.

A delayed medication can mean worsening symptoms.

A delayed treatment plan can mean a preventable crisis.

And for chronic conditions, cancer care, maternal health, HIV prevention and treatment, mental health, eye health, and other areas where timing matters, delays can change outcomes.

Prior authorization is often described as an administrative process, but for patients it is deeply personal. It determines whether a person can access care now, later, or sometimes not at all.

This is also why prior authorization has become a national policy conversation.

Recent reporting and analysis show that the scale of the issue is significant. In Medicare Advantage alone, insurers made nearly 53 million prior authorization determinations in 2024. Millions of requests were denied in whole or in part. Even more telling, only a small share of denials were appealed, but among those that were appealed, most were ultimately overturned. That means many patients and providers may be facing delays or denials for care that, after additional effort, is found to be appropriate or covered.

That should give all of us pause.

If a denial can be overturned after an appeal, what happens to the patient who does not know how to appeal? What happens to the caregiver who is already overwhelmed? What happens to the person who cannot take time off work to chase paperwork? What happens to the patient whose doctor’s office does not have enough staff to keep fighting with the insurance company?

The burden does not fall evenly.

Patients with resources, flexible jobs, digital access, health literacy, and strong provider support may be better positioned to push through the process. Patients without those supports may simply be left waiting. Or worse, left without care.

This is not just inefficient. It is inequitable.

There is some movement toward reform. Federal policymakers have finalized rules intended to make prior authorization more transparent and easier to manage for certain payers. Those rules include requirements for impacted payers to provide more specific reasons when prior authorization requests are denied. Major insurers have also made voluntary commitments to reduce the number of services requiring prior authorization, increase transparency, and move toward more standardized electronic processes.

These are important steps, but they are not the finish line.

Promises must translate into real change for patients. A faster portal does not solve the problem if the answer is still unclear. A reduced list of services does not help if high-stakes treatments remain difficult to access. A denial reason does not advance equity if patients still cannot understand or act on it. And technology should never make it easier to deny care faster without meaningful accountability.

That concern is especially urgent as artificial intelligence becomes more involved in healthcare administration. AI may have a role in improving efficiency, but when it is used in prior authorization, the stakes are high. Coverage decisions must be transparent, clinically sound, and subject to human review. Patients should never be trapped inside an algorithmic process they cannot see, understand, or challenge.

This is where equity must guide the conversation.

Prior authorization reform should not only be about speed. It should be about fairness, accountability, and access. It should ask whether patients can understand the process, whether providers can navigate it without sacrificing clinical time, whether denials are appropriate, whether appeals are accessible, and whether certain communities are being delayed or denied more often than others.

For BWHI, this issue is connected to our broader fight for healthcare access, affordability, quality, and equity. When we talk about coverage, we are not only talking about whether someone has an insurance card. We are talking about whether that coverage actually works when they need care.

Coverage that exists on paper but delays care in practice is not enough.

Prior authorization can affect many areas of care, including specialty medications, diagnostic imaging, cancer screenings, surgeries, medical devices, physical therapy, HIV prevention and treatment, and chronic disease management. In eye health, for example, patients living with conditions such as glaucoma or ocular hypertension may face prior authorization requirements before accessing newer treatment options. For conditions where delay can increase risk, coverage rules must be designed with patients in mind.

A healthcare system worthy of our communities should not require people to become professional paperwork chasers to receive medically recommended care.

Black women deserve a system that listens the first time. A system that respects clinical judgment. A system that explains decisions clearly. A system that makes appeals accessible. A system that uses technology responsibly. A system that does not hide cost-control decisions behind confusing language and administrative burden.

Prior authorization may sound like a technical insurance issue, but it is really a question of power.

Who gets to decide when care is necessary?

How long should patients have to wait?

Who is accountable when delays cause harm?

And whose lives are most affected when the system decides to slow care down?

As prior authorization reform moves forward, BWHI will continue to advocate for policies that are transparent, timely, patient-centered, and equitable. Because care delayed is too often care denied, and Black women and our families deserve better than a system that makes us fight for the care we need.

Yes. I’d make the blog more substantive by showing that prior authorization is not just “red tape.” It is a live national policy debate touching Medicare Advantage, insurer reform pledges, AI in coverage decisions, specialty care, and transparency.

Here are the topical sources I would anchor the blog around:

CMS finalized a prior authorization rule requiring impacted payers to provide specific denial reasons beginning in 2026, with API-related requirements largely taking effect in 2027. The rule does not apply to drug prior authorization decisions. (CMS)

KFF reported that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024 and denied 4.1 million requests, or 7.7%. Only 11.5% of denied requests were appealed, but more than 80% of appealed denials were overturned, which is a powerful point about patients and providers being forced to fight for care that may ultimately be approved. (KFF)

The AMA’s 2025 physician survey found that 95% of physicians say prior authorization delays access to necessary care, 79% say patients abandon treatment because of authorization challenges, and 26% report prior authorization has led to a serious adverse event. (American Medical Association)

In June 2025, major insurers made a voluntary pledge to reduce and streamline prior authorization, including moving toward standardized electronic submissions by January 1, 2027, and reducing the number of services requiring prior authorization by January 1, 2026. Reuters reported the pledge included major insurers such as UnitedHealthcare, Aetna, Cigna, Humana, Blue Cross Blue Shield Association, and Kaiser Permanente. (Reuters)

This year, the issue has stayed in the headlines because insurers have announced cuts to prior authorization requirements, including UnitedHealthcare’s May 2026 announcement that it would eliminate prior approval requirements for 30% of healthcare services. (Reuters)

The AI angle is also current. CMS’s WISeR model is testing prior authorization in traditional Medicare in six states from January 1, 2026 through December 31, 2031, and critics have raised concerns about delays, denials, transparency, and algorithmic decision-making. (CMS)

Here is a more substantive blog draft you can use and shape:

Prior Authorization: When Getting Approval Becomes a Barrier to Getting Care

Most people do not think about prior authorization until they are stuck waiting for it.

A doctor recommends a medication, procedure, test, device, or treatment. The patient is ready to move forward. The provider is ready to deliver care. But before that care can happen, the health plan may require one more step: approval.

That step is called prior authorization.

In theory, prior authorization is meant to confirm that care is medically necessary, appropriate, and covered by a patient’s health plan. It can be used as a tool to manage costs, avoid unnecessary care, and encourage evidence-based treatment.

But in real life, prior authorization can become something else entirely. It can become a delay. It can become a denial. It can become a stack of forms, phone calls, portals, appeals, and confusion. And for patients who are already trying to navigate a complicated healthcare system, that delay can feel like the system is asking them to prove they deserve the care their clinician already said they need.

That is why prior authorization has become one of the most important healthcare access issues of this moment.

Across the country, patients, physicians, advocates, policymakers, and even insurers are acknowledging that the current process is not working the way it should. It is too often slow, inconsistent, opaque, and burdensome. When approvals are delayed, patients may wait longer for diagnostic tests, specialty care, procedures, medications, or treatment plans. Some may give up altogether. Others may get sicker while waiting.

For Black women and our families, this issue deserves special attention.

Black women already face too many barriers to timely, respectful, affordable, high-quality care. We are more likely to have our symptoms dismissed, more likely to experience delays in diagnosis, and more likely to carry the weight of a healthcare system that was not designed with our full humanity at the center. When prior authorization adds another hurdle, it does not land in a neutral system. It lands in a system already shaped by inequity.

A delayed approval can mean delayed pain relief.

A delayed diagnostic test can mean a delayed diagnosis.

A delayed medication can mean worsening symptoms.

A delayed treatment plan can mean a preventable crisis.

And for chronic conditions, cancer care, maternal health, HIV prevention and treatment, mental health, eye health, and other areas where timing matters, delays can change outcomes.

Prior authorization is often described as an administrative process, but for patients it is deeply personal. It determines whether a person can access care now, later, or sometimes not at all.

This is also why prior authorization has become a national policy conversation.

Recent reporting and analysis show that the scale of the issue is significant. In Medicare Advantage alone, insurers made nearly 53 million prior authorization determinations in 2024. Millions of requests were denied in whole or in part. Even more telling, only a small share of denials were appealed, but among those that were appealed, most were ultimately overturned. That means many patients and providers may be facing delays or denials for care that, after additional effort, is found to be appropriate or covered.

That should give all of us pause.

If a denial can be overturned after an appeal, what happens to the patient who does not know how to appeal? What happens to the caregiver who is already overwhelmed? What happens to the person who cannot take time off work to chase paperwork? What happens to the patient whose doctor’s office does not have enough staff to keep fighting with the insurance company?

The burden does not fall evenly.

Patients with resources, flexible jobs, digital access, health literacy, and strong provider support may be better positioned to push through the process. Patients without those supports may simply be left waiting. Or worse, left without care.

This is not just inefficient. It is inequitable.

There is some movement toward reform. Federal policymakers have finalized rules intended to make prior authorization more transparent and easier to manage for certain payers. Those rules include requirements for impacted payers to provide more specific reasons when prior authorization requests are denied. Major insurers have also made voluntary commitments to reduce the number of services requiring prior authorization, increase transparency, and move toward more standardized electronic processes.

These are important steps, but they are not the finish line.

Promises must translate into real change for patients. A faster portal does not solve the problem if the answer is still unclear. A reduced list of services does not help if high-stakes treatments remain difficult to access. A denial reason does not advance equity if patients still cannot understand or act on it. And technology should never make it easier to deny care faster without meaningful accountability.

That concern is especially urgent as artificial intelligence becomes more involved in healthcare administration. AI may have a role in improving efficiency, but when it is used in prior authorization, the stakes are high. Coverage decisions must be transparent, clinically sound, and subject to human review. Patients should never be trapped inside an algorithmic process they cannot see, understand, or challenge.

This is where equity must guide the conversation.

Prior authorization reform should not only be about speed. It should be about fairness, accountability, and access. It should ask whether patients can understand the process, whether providers can navigate it without sacrificing clinical time, whether denials are appropriate, whether appeals are accessible, and whether certain communities are being delayed or denied more often than others.

For BWHI, this issue is connected to our broader fight for healthcare access, affordability, quality, and equity. When we talk about coverage, we are not only talking about whether someone has an insurance card. We are talking about whether that coverage actually works when they need care.

Coverage that exists on paper but delays care in practice is not enough.

Prior authorization can affect many areas of care, including specialty medications, diagnostic imaging, cancer screenings, surgeries, medical devices, physical therapy, HIV prevention and treatment, and chronic disease management. In eye health, for example, patients living with conditions such as glaucoma or ocular hypertension may face prior authorization requirements before accessing newer treatment options. For conditions where delay can increase risk, coverage rules must be designed with patients in mind.

A healthcare system worthy of our communities should not require people to become professional paperwork chasers to receive medically recommended care.

Black women deserve a system that listens the first time. A system that respects clinical judgment. A system that explains decisions clearly. A system that makes appeals accessible. A system that uses technology responsibly. A system that does not hide cost-control decisions behind confusing language and administrative burden.

Prior authorization may sound like a technical insurance issue, but it is really a question of power.

Who gets to decide when care is necessary?

How long should patients have to wait?

Who is accountable when delays cause harm?

And whose lives are most affected when the system decides to slow care down?

As prior authorization reform moves forward, BWHI will continue to advocate for policies that are transparent, timely, patient-centered, and equitable. Because care delayed is too often care denied, and Black women and our families deserve better than a system that makes us fight for the care we need.

READ MORE:

1. CMS Interoperability and Prior Authorization Final Rule
   Use this for the federal policy reform angle. (CMS)
2. KFF: Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024
   Use this for the “scale of the issue” data. (KFF)
3. AMA: Prior Authorization Reform Pledge Falls Short, Physicians Say
   Use this for provider burden and patient harm stats. (American Medical Association)
4. Reuters: Insurers Pledge Prior Authorization Reform
   Use this to show why the issue is in the news now. (Reuters)
5. HealthCare Dive or CMS WISeR page on AI and prior authorization
   Use this to make the blog feel forward-looking and current. (Healthcare Dive)