On March 31, CMS required payers to publicly report prior authorization denial rates, turnaround times, and appeal outcomes for the first time. That single mandate will generate more actionable data about how insurers use prior authorization than 2 decades of physician complaints combined. And it is a reform measure, not an abolition measure. That distinction matters.
I am not here to defend the current system. The current system is indefensible. A Health Affairs analysis pegged the combined cost at $62.5 billion annually: $26.7 billion on the physician side, $35.8 billion on the patient side. The American College of Gastroenterology surveyed its members and found 97% reported prior authorization worsened patient care, with 83% linking delays directly to hospitalizations. Over 40% of New York physicians in a separate survey reported prior authorization delays led to serious adverse outcomes. These numbers describe a broken process. They do not describe a process that should cease to exist.
The Fraud Problem Nobody Wants to Talk About
CMS launched the WISeR Model on January 1, 2026, in 6 states specifically to combat fraud in traditional Medicare's outpatient services. This is CMS expanding prior authorization, not retreating from it. The agency looked at the data on fraudulent billing patterns and concluded that some form of pre-service review is necessary to protect taxpayer dollars and, more importantly, patients who receive unnecessary procedures.
Indiana Governor Mike Braun's pledge sounds wonderful: "If your doctor says you need it, you'll get it." I admire the simplicity. I also note that it assumes every physician recommendation is clinically appropriate, which contradicts everything we know about practice variation, defensive medicine, and financial incentives in fee-for-service models. The Dartmouth Atlas has documented geographic variation in Medicare spending of 2 to 3 fold for decades. Some of that variation is overuse. Prior authorization, badly as it functions now, is one of the few mechanisms that even attempts to address it.
Abolition advocates deserve credit on one point: the appeal rate is damning. Only 1 in 10 denials were appealed in 2022 according to KFF data, which suggests the system discourages legitimate challenges through sheer friction. That is a design failure, not a reason to eliminate the design category.
What the Evidence Actually Supports
The Improving Seniors' Timely Access to Care Act has 248 House co-sponsors and 64 Senate co-sponsors. Read the bill. It does not abolish prior authorization. It mandates electronic processing, real-time decisions for routine services, and transparency requirements. The AMA and over 120 specialty societies endorsed it. The bill's framework traces back to a 2018 consensus statement that included health plans at the table. Insurers agreed to these principles.
The CMS Interoperability and Prior Authorization Final Rule, effective January 2026, requires FHIR-based APIs and electronic prior authorization capabilities across Medicare Advantage, Medicaid, CHIP, and exchange plans. Standardized electronic infrastructure by January 2027. Senator Whitehouse's Prior Authorization Relief Act would exempt providers in two-sided risk models entirely, which is elegant: if you bear financial risk for outcomes, you have already internalized the cost-containment incentive.
These are not half-measures. They are structural changes that address the specific failures: opacity, slowness, lack of clinical input, and the absence of accountability when denials cause harm. The ACG found that zero peer-to-peer reviews in GI cases involved an actual gastroenterologist on a weekly basis. That is fixable. Require specialty-matched reviewers. Mandate 24-hour turnaround for urgent requests. Publish denial data so employers and patients can choose plans accordingly.
Abolishing prior authorization feels satisfying the way abolishing speed limits feels satisfying when you are stuck in traffic. The frustration is real. The solution is wrong. You do not remove the only utilization check in a $4.5 trillion healthcare system because insurers have implemented it badly. You force them to implement it well, with enforceable timelines, transparent criteria, and consequences for denials that cause patient harm.
CMS just handed us the data infrastructure to know, for the first time, which plans deny the most and delay the longest. The rational move is to use that information, not to pretend we never needed it.
