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Your weekend long read. America's Health Insurance Plans (AHIP) announced six voluntary commitments in June to reform the prior authorization process for medical benefits. These commitments were developed in close cooperation with the Trump Administration after an October 2024 survey of prior authorization practices among AHIP members.
We now have some analysis, courtesy of RealClearHealth and Paragon Health Institute. First, the Paragon White Paper:
RealClearHealth Research & Analysis
In August, AHIP—the trade association representing the nation’s largest health insurers—announced a set of voluntary commitments, developed in coordination with the White House, aimed at reforming prior authorization for medical benefits. While some advocates have welcomed the announcement as a constructive step toward industry-led reform, significant questions remain about the scope, enforceability, and real-world impact of AHIP’s six-point proposal, particularly given its exclusion of pharmaceutical benefits. This RealClear white paper, produced in partnership with Jackson Hammond of the Paragon Health Institute, evaluates those commitments in the context of how prior authorization is currently used across public and private insurance, the documented costs and savings associated with the practice, and the growing concerns raised by patients and providers. It examines whether AHIP’s pledges meaningfully address administrative burden and delays in care, or whether further action—especially around reducing the scope of services subject to prior authorization—is necessary to balance cost control with timely access to clinically appropriate treatment.
Jerry Rogers, Editor RealClearHealth
Prior Authorization: AHIP’s Commitments - Analysis and Considerations
By Jackson Hammond - December 18, 2025Introduction
In August, AHIP, the trade association for health insurance companies representing the industry’s top players, announced that they reached a deal with the White House to reform prior authorization for medical benefits.[1] This announcement has been viewed by some advocates as a step in the right direction for industry-based reform. But questions remain about the insurance industry’s commitment to reforming prior authorization, as well as the practicality and scope of what they have promised. Notably, these commitments appear to exclude pharmaceutical benefits. This brief will focus on three areas. First, it will provide an overview of the current general use and impact of prior authorization in both public and private insurance programs. Second, it will review AHIP’s announced commitments. And finally, it will touch on potential areas of consideration for stakeholders.
Background
What Is Prior Authorization?
Prior authorization is the requirement that a patient and their physician obtain approval from the insurer for a given medical procedure or medicine before the insurer will pay for that specific procedure or medicine. It is a “utilization management” mechanism used by insurers to control costs and ensure appropriate treatment. Medicines and procedures subject to prior authorization run the gamut from medical imaging to surgeries to drugs to lab tests.
Most private payers have prior authorization requirements, including commercial and employer-sponsored plans. Although traditional Medicare only has prior authorization requirements in extremely limited cases, Medicare Advantage plans often do. States and Medicaid managed care organizations are allowed to require prior authorizations as well.
Data on the total number of treatments subject to prior authorization is difficult to come by. One study found that 31.8 percent of Part B services were subject to prior authorization by at least one Medicare Advantage insurer.[2] The same study found that 74 percent of Part B medication use (and 93 percent of medication spending) was subject to prior authorization by at least one Medicare Advantage insurer. A 2023 Milliman analysis of private payers estimates that around 41.2 percent of allowed prescription drug costs are subject to prior authorization in the commercial market.[3]
Data from Medicare Advantage shows that 93.6 percent of prior authorization requests are approved, and 81.7 percent of denials are overturned on appeal.[4] An AHIP survey found that for initial prior authorization denials, 86 percent were the result of incomplete clinical documentation, while 34 percent of final prior authorization denials were due to incomplete clinical documentation.[5]
Savings from Prior Authorization
Prior authorization is one of the primary cost-control tools that insurers have. Analysis by Milliman found that if prior authorization were to be eliminated in the commercial insurance market for a “broad” range of services (defined as 26.3 percent of services), enrollees would see an estimated 4.8 percent increase in monthly premiums.[6] Eliminating prior authorization for a “narrow” range of services (defined as 8.8 percent of services) would increase monthly premiums by an estimated 3.3 percent. Milliman also estimated that due to increased utilization, out-of-pocket expenses for individuals would increase by 2.6 percent for a broad scope of services, or 1.0 percent for a narrower scope of services. All told, Milliman estimated that total premium increases could range from $43 to $63 billion annually if prior authorization were eliminated.
One specific type of prior authorization is known as step therapy. Step therapy requires patients to first try different medications before their medication of first choice is covered. Step therapy is often applied to pharmaceuticals, and in particular expensive specialty drugs. One 2019 review found step therapy for specialty medications reduced insurer costs by between 9 and 11 percent.[7]
Patient and Provider Concerns
A 2023 KFF survey of insured individuals found that 16 percent of all insured adults experienced prior authorization issues in the previous 12 months.[8] This varied by insurance type: 22 percent of those covered under Medicaid, 15 percent with employer-sponsored coverage, and 11 percent of those with Medicare experienced issues with prior authorization. These issues frequently included either delays or denials of care. Of those surveyed, 34 percent with prior authorization issues “were unable to receive medical care or treatment recommended by a medical provider,” while 32 percent experienced “significant delays in receiving medical care or treatment.” In addition, certain health conditions had higher rates of prior authorization issues. Of those who sought treatment for mental health conditions, 26 percent had prior authorization issues, compared to 13 percent for those who did not seek mental health treatment. For individuals who sought out treatment for diabetes, 23 percent experienced prior authorization issues while only 8 percent of individuals who had not sought treatment for diabetes did. Notably, 26 percent of surveyed individuals who experienced prior authorization issues reported a decline in their health of some degree.
For physicians, prior authorization requirements add paperwork burdens as well as create issues for patient care. A 2024 physician survey by the American Medical Association (AMA) found that physician practices average 43 prior authorizations per physician per week, and that physicians and their staff spend around 12 hours completing prior authorizations each week.[9] Of the physicians surveyed, 87 percent said prior authorization led to higher overall health care utilization, 79 percent said it led to patients paying out-of-pocket for medications, 69 percent reported it led to ineffective initial treatments (due to step therapy or other requirements), and 29 percent reported hospitalizations.
AHIP’s Commitments
AHIP stated that, moving forward, its members—including most major insurance companies—would seek to implement six new reforms to its prior authorization process, including: standardizing electronic prior authorization, reducing the scope of medical claims subject to prior authorization, ensuring continuity of care, enhanced communications and transparency, enabling real-time responses for 80 percent of electronic prior authorization requests, and ensuring medical review of non-approved requests.
These commitments are not legally binding and are the result of political pressure from both the Trump administration as well as patient and provider groups. Whether insurers will follow through on these promises remains to be seen. However, internal industry reforms are almost always preferable to reforms imposed by regulators or policymakers that may not conform to the realities of the insurance market.
Standardizing Electronic Prior Authorization
Different insurers use different prior authorization systems and have different rules for those systems. These differences add time and complexity to the prior authorization process. AHIP members plan to begin using standardized data and submission requirements by January 1, 2027. The largest barrier to this commitment is likely to be the transition time for adoption by providers and plans agreeing on a shared system and set of rules.
Most medical plans do not have fully electronic prior authorization. According to a report by the insurance industry analysis firm Council for Affordable Quality Healthcare, as of 2024 only 35 percent of medical plans have fully electronic prior authorization processes.[10] The rest are either partially electronic or fully manual (using phone, mail, fax, and emails).
Reducing the Scope of Medical Claims Subject to Prior Authorization
Insurers have pledged to “commit to specific reductions to medical prior authorization as appropriate for the local market each plan serves” by January 1, 2026. This commitment has sparked the most interest by patients, providers, and politicians. Given the large number of services subject to prior authorization—according to one study, 48 percent of service utilization in Part B would have required prior authorization by at least one Medicare Advantage insurer—reducing the number of services that require prior authorization is considered a priority by patient and provider groups.[11] However, this is also the area that will most directly impact costs for insurers; the less prior authorization there is, the more their costs (and thus premiums) will increase. As such, many critics are doubtful that the self-assessed measure of “specific reductions…as appropriate for the local market” will yield any significant changes. It is important to highlight that this commitment is for the medical benefit—excluding prescription drugs, where most prior authorization is encountered.
Ensuring Continuity of Care
Starting January 1, 2026, if an enrollee switches plans mid-treatment, insurers have committed to honor existing prior authorizations for benefit-equivalent in-network services for 90 days. Ideally, this will prevent patients who switch plans from experiencing continuity of care issues or delays in care. This will require some significant coordination between competing plans, with little incentive beyond a non-binding commitment to do so.
Enhanced Communication and Transparency for Determinations
Insurers have promised to provide “clear, easy-to-understand explanations of prior authorization determinations,” including guidance for appeals and next steps, starting on January 1, 2026 for fully insured and commercial plans. Insurers claim they need regulatory changes in order to expand this promise to other types of coverage and promise to support those changes. Even if there is more transparency around prior authorization denials, that may not make the denial any easier to reverse.
Expanding Real-Time Responses
Insurers pledged to have at least 80 percent of electronic prior authorization approvals answered in real-time. This pledge involves adopting new technologies that will be part of the commitment to standardization. With the rapid pace of improvements in AI technology, this pledge is achievable and some insurers may have been well on their way already to fulfilling this commitment. However, as noted above, only 35 percent of plans had electronic prior authorization in 2024. This number has grown significantly from 21 percent in 2021. Technology will continue to improve, but achieving this goal in 2027 would still mean only 28 percent of plans will have fully electronic prior authorization.
Ensuring Medical Review of Non-Approved Requests
Insurers have “committed” to continuing to affirm that all non-approved requests (based on clinical reasons) are reviewed by medical professionals. Critics contend that in many cases, these medical professionals are not specialists in the relevant fields.[12]
Considerations Going Forward
While skepticism by patients and providers regarding insurers’ willingness to follow through is reasonable, insurers should be commended for making voluntary commitments to reform prior authorization. Private industry action will be better-informed and far less disruptive and costly than bureaucratic regulation. The most important of these reforms—both politically and financially—will be the reduction in the scope of claims subject to prior authorization.
The following framework is meant to be a tool to help insurers make these important scope reduction decisions. Importantly, this framework should be understood as a guide for payers working in collaboration with patients and providers and is not intended to be a legislative or regulatory framework.
Burden on Patients
Insurers should consider the level of burden on a patient that delays in care will cause. This includes both the severity of symptoms as well as the immediacy of the problem. Conditions with symptoms that incapacitate a patient should be at the forefront of consideration for reduced prior authorization requirements. Conditions that are immediate issues (as opposed to elective surgeries that can be put off for months or years) should also be considered. It should be an imperative to avoid cases where surgeons are called in the middle of surgery for prior authorization, as at least one news report has alleged.[13]
Little-To-No Evidence of Fraud or Abuse
Insurers should factor in conditions that are not particularly prone to fraud or abuse. This is admittedly easier said than done. The “sentinel effect,” whereby the mere existence of a watchman deters crime, is likely happening across various medical conditions and treatments that currently show little evidence of fraud or abuse. However, distinction is possible. Insurers should consider the likelihood and harm of overutilization (e.g., the overprescribing of opioid pain medications prior to legislative reforms in the late 2010s) or game-ability of a condition or service (skin substitute manufacturers taking advantage of Part B payment rules).[14] Insurers should ask if the treatments for a given condition provide a larger financial benefit to the provider relative to their efficacy compared to another treatment.
Consistently High Claims Approvals
Treatments that are consistently and frequently approved are an obvious candidate for reduced prior authorization requirements. There is little reason to have onerous processes for treatments that routinely receive approval. Insurers have already begun to experiment with similar concepts: UnitedHealthcare introduced a Gold Card program in 2024 that would allow providers who receive consistently high approval rates to have reduced prior authorization requirements.[15] Insurers should consider the same for treatments that are routine.
Existing Evidence Base for Treatment
Insurers may also want to consider reducing prior authorization requirements for treatments that are considered “best practices” by the appropriate medical society. These treatments ideally should be shown to be effective for a significant portion of patients and have been long-standing clinical practice. This does not mean that “older is better,” but simply that newer treatments might need a stronger evidence base than older ones.
Inclusion of Pharmaceuticals
Although AHIP excluded pharmacy benefits from its commitments, insurers should consider applying all their prior authorization reforms, and especially their scope-of-claims reductions, to pharmaceutical benefits. Drugs generally face higher rates of prior authorization and are the cause of much of patient and provider frustration (which in turn increases political pressure). Insurers should include patient history of treatments in their considerations as well; for example, if the patient has a documented history of a given drug working, re-approvals for that treatment may not need to be as frequent.
Sample Conditions and Services
The following list of conditions and services is by no means comprehensive and is meant to be illustrative of how insurers could apply this framework:
- Chronic Migraine: This condition frequently causes patients to experience debilitating pain and they are often unable to work or go about daily life. The impact on patient quality of life and the overall economy is significant[16]. Many plans require patients to fail on at least two triptans, a class of older, less-expensive drugs.[17] There is little incentive for overutilization of treatments by patients, as opioids are rarely prescribed for migraine.[18] Migraine specialists report that the vast majority of their patients get approval after meeting the various step therapy and other requirements—in other words, approval is routine, albeit slow.[19] However, we also know that if not effectively treated, migraine disease can worsen or progress. The American Headache Society, the professional society for migraine specialists, recently released a position statement advocating for newer, migraine-specific medications to be used first before having to try anything else. [20]
- Cancer care: The burden on patients is obvious as untreated cancer is lethal. One survey found that 96 percent of physicians said their patients were harmed by prior authorization delays.[21] Approval rates are also around 90 percent, so most people are eventually approved.[22] However, cancer drugs are very expensive and insurers cannot be expected to remove all prior authorization requirements. In addition, specific classes of cancer drugs may be considered “best practice” by oncology societies, but individual responses to those drugs vary widely, and different cancers respond differently to treatment.
- Magnetic Resonance Imaging (MRI): The immediacy of the issue and patient burden varies depending on the severity of the condition being examined. An athlete with a torn ACL does not have the same immediacy issue as someone facing internal bleeding. MRIs have an approval rate of over 94 percent—meaning ultimately most insurers think they are worth it.
Conclusion
Prior authorization is an important tool for insurers to control costs and keep premiums lower than they otherwise would be. However, it is in many cases a significant burden for patients and providers. Reducing this burden increasingly appears to be a political necessity for payers. Insurers should consider using the above framework in making decisions about what services and treatments should see reduced prior authorization requirements. In addition, they should also consider expanding their commitments to include pharmaceutical benefits. Conditions such as people living with migraine, cancer care and MRI fit within the proposed framework for making these decisions and would serve as a strong starting point to illustrate progress.
This Paragon White Paper has 22 footnotes which can be accessed at the middle hyperlink, above.
The Paragon White Paper provoked these comments from the editors of RealClearHealth:
Examining AHIP’s Pledges on Prior Authorization
By The Editors - December 18, 2025In a RealClearHealth paper published this week, Prior Authorization: AHIP’s Commitments, Paragon Health Institute's Jackson Hammond explores recent actions taken by America’s Health Insurance Plans (AHIP) in partnership with the Trump Administration to look at reforms to when and how individuals are subjected to an insurance tool called prior authorization. First announced in July of 2025, AHIP has specifically made commitments to “streamline, simplify and reduce prior authorization,” and the paper builds out a solid framework for insurers as they consider where best to focus their efforts.
While some may be rightfully skeptical about where progress on prior authorization can be made in 2026 and beyond, AHIP’s commitments directly align with the Trump Administration’s efforts to remove barriers to access and drive down health care costs for everyday Americans – striking a balance between areas where prior authorization is a useful tool to protect against waste, fraud, and abuse, and reducing reliance on prior authorization where sound evidence supports patient and provider decision-making.
These efforts are also important to show that common sense policy changes can be implemented, and implemented quickly, without the need for legislative or regulatory action. By coming to the table to proactively address potential inefficiencies and cost drivers, payers are directly responding to criticisms of the program’s flaws and stepping up to deliver real savings for the American people.
Medical societies, patient advocates, and others have long argued for changes to prior authorization for a range of diseases, treatments, and procedures – citing a number of stressors and potential poor health outcomes that can result from delayed or denied treatment. Study after study finds that a majority of Americans now identify prior authorization as a major challenge to receiving the care that they and their doctors believe they need – with the half of all insured adults subjected to prior authorization requirements in the last two years reporting personal difficulty in navigating the complex process.
Delayed care and abandoned treatment can lead to costly complications and repeat emergency room visits for untreated or worsening conditions, adding health care costs where prior authorization had intended to contain them. Additional costs to the system come in the form of time intensive paperwork and processes that providers face when working to obtain access to their recommended treatment for a patient or appeal a denial.
This also results in a direct impact to the American workforce and productivity as providers are spending more time addressing prior authorization claims versus actually seeing patients, and employees are forced to take time away from work to navigate the process for themselves or a family member.
For all of these reasons, it makes sense for AHIP to commit to exploring improvements to how, when, and why prior authorization policies are used – not only for medical claims as laid out in their commitment statement but also for pharmaceutical claims, which is of interest to CMS and the Administration.
As touched on in the paper, patients with migraine may hold the key. Migraine affects around 40 million people in the United States, less than half of which are diagnosed and fewer still on medication. It disproportionally affects women by large margins and often throughout their lifetimes.
Many people living with migraine self-manage their mild-to-moderate migraine attacks with over-the-counter medications, while others with acute migraine seek prescription medications or other medical treatments such as injections or nerve blockers. Frustratingly for patients, even when they seek medication they are often faced with process barriers to receiving the newer treatments that have recently entered the market – treatments that the American Headache Society now says should be frontline options for those with migraine.
Beyond the impact this has on Americans who are living with migraine, the effects on our national economy are also considerable. Direct cost estimates vary between those with episodic versus chronic migraine, but on an annualized per patient level exceed $2,500 and $8,000, respectively. Costs to the economy in these estimates include a wide range of 60,000 to 600,000 lost workdays across sectors, and indirect cost estimates around 6 to 9 times higher than annual direct patient costs. These are Americans who want to go to work, live their lives, and contribute to society, but are being held back by the inability to properly treat their migraines.
In short, the science underpinning new treatments, the economic impact of inefficient care, and the substantial population of Americans who are suffering from migraine without the ability to properly treat it, all point toward migraine as an area where reduced reliance on stringent prior authorization mechanisms would be a win for all involved.
The insurers participating in AHIP’s efforts on prior authorization, the Trump Administration, and other advocates of utilization management reform have demonstrated an important interest in getting these tools right – and the near-term chance to demonstrate tangible health outcome and economic benefits in migraine care provides a unique pilot area to do so.
RealClearHealth
No better, according to Becker's Health summary.
The unraveling of prior authorization: 5 things to know
Francesca Mathewes | May 22nd, 2026
Prior authorization has been under intense scrutiny in recent months as frustration brews among clinicians and legislators aim to curb the use of AI technology in the practice.
Here are five recent developments reshaping the way prior authorization is deployed in healthcare settings and payer claims processing:
1. Democratic lawmakers introduced resolutions in the House and Senate to overturn CMS’ Wasteful and Inappropriate Services Reduction (WISeR) model, an AI-assisted prior authorization initiative under traditional Medicare..
CMS launched WISeR at the start of 2026, with plans to run the model through the end of 2031 in Washington, New Jersey, Ohio, Oklahoma, Texas and Arizona. The model applies prior authorization requirements to select traditional Medicare services and relies on for-profit contractors using AI tools to process requests and reviews. Democrats have attempted to block WISeR through multiple legislative avenues since CMS announced the model last June, including appropriations amendments and standalone legislation, without success.
2. Last year over 60 major health insurers pledged to streamline prior authorization processes — but few physicians think these pledges have made a difference in PA burden, according to the American Medical Association’s “2025 AMA Prior Authorization Physician Survey” released May 13. Recently, UnitedHealthcare reaffirmed this pledge, saying it would pare down PA for 30% of applicable services.
Despite the recent promises and the 2018 “Consensus Statement on Improving the Prior Authorization Process” being released nearly 7 years before this survey, physicians report health plans have made little progress honoring their commitments. Only 16% of physicians working with UHC and 16% working with Cigna say those changes actually reduced the number of PAs they complete.
3. Iowa Republican Gov. Kim Reynolds signed a law May 13 that enacts prior authorization reforms and prohibits insurers from penalizing providers for out-of-network referrals, according to the Iowa Hospital Association.
Under the law, while initial prior authorization reviews can be done by AI, these algorithms and systems cannot be the sole basis for determining denials, downgrades or delays. Health insurance carriers cannot impose fines or other financial penalties due to a provider’s referral to an out-of-network provider, either.
4. North Carolina lawmakers are also deliberating a bill that would limit AI’s use in healthcare, primarily in relation to how it is used in billing and claims denials. House Bill 565 would prohibit payers from using AI as the sole basis for denying healthcare claims or prior authorization requests.
5. PA continues to be a significant burden for physicians and patients, according to the AMA’s recent survey. Ninety-three percent of physicians reported that PA can cause care delays at least some of the time, while 82% reported that PA can at least sometimes lead to patients abandoning treatment plans. Notably, zero physicians in the survey said PA never caused treatment plan abandonment.
We're now past the 13-month mark.
Beckers provides a 360-degree update. Many source links recommended at the original post.
The beginning of the end for prior authorization?
Francesca Mathewes | August 25, 2026
For nearly as long as health insurers have used prior authorization to control costs, physicians and hospitals have argued it does more harm than good.
The pushback against prior authorization has reached new heights in recent months as healthcare leadership, legislators and physician advocacy organizations have proposed major reforms or outright bans of the practice.
Here are 10 notes on where things stand.
1. A health insurance CEO says prior authorization should be illegal. Patrick Quigley, CEO of El Segundo, Calif.-based Sidecar Health, told Becker’s that the industry’s signature cost-control tool creates more waste than it prevents.
“We are creating massive amounts of waste in our system, and we are controlling cost within the system simply by denying care,” he said.
Mr. Quigley argued the fix isn’t reforming prior authorization — it’s eliminating it. “The right path is actually to stop and make prior authorization illegal,” he said. “Why do we need prior authorization at all? Instead, focus on creating transparency around decisions, around costs, around quality, so that people can naturally make better decisions, because that’s going to lower costs.”
2. The denial data behind his frustration is now public. Under new reporting requirements, Medicare Advantage, Medicaid managed care and ACA marketplace plans must publicly disclose how often they deny prior authorization requests and how often those denials get overturned on appeal. A KFF analysis found denial rates ranging from 12% to 18% across the three markets, while appeal overturn rates hit 67% for Medicare Advantage, 47% for Medicaid and 43% on the marketplace — including one insurer, Centene, that overturned 93% of its appealed Medicare Advantage denials. About 150 million Americans with employer-sponsored coverage aren’t captured by the reporting requirement at all.
3. The lack of transparency around prior auth has a price tag. A policy brief from the American Economic Liberties Project, cited alongside Mr. Quigley’s case for banning prior authorization, put the administrative burden created by the process at the equivalent of more than 99,000 full-time clinicians and up to $32.7 billion a year.
4. CMS just closed transparency loopholes the AMA says insurers were exploiting. The 2024 Interoperability and Prior Authorization rule requires health plans to publicly post their prior authorization requirements and outcomes. But when the American Medical Association reviewed 15 Medicare Advantage contracts, it found plans technically complying while making the information nearly impossible to use — hundreds of pages of billing codes with no plain-language explanation, disclosures buried behind password-protected portals, and entire categories of care omitted altogether.
“Patients should not need a portal password, a billing manual or medical training to find and understand a health plan’s prior authorization practices,” said Willie Underwood III, MD, president of the American Medical Association.
Following the AMA’s findings, CMS updated its guidance to clarify that password-protected portals don’t satisfy disclosure requirements and to require plain-language descriptions, standardized service categories and machine-readable formats. Dr. Underwood called it “an important step,” but said “the work is not finished.”
5. Insurers say their pledges are working. Physicians see something different. About 50 insurers covering 257 million Americans committed in June 2025 to streamline prior authorization. AHIP and the Blue Cross Blue Shield Association have since reported an 11% reduction in requirements, with some Medicare Advantage plans exceeding 15%.
“During the past 10 months, the Blues made significant, measurable strides toward delivering on our promise to make this process faster, simpler and more transparent,” said Kim Keck, CEO of the Chicago-based Blue Cross Blue Shield Association.
Physicians report a different reality. In an AMA survey, 94% said prior authorization negatively affects patient outcomes, and just 1% reported a positive impact; 26% documented serious adverse events tied to a delay or denial, including hospitalization (23%), a life-threatening event (18%) or disability or death (8%). Among physicians who contract with UnitedHealthcare and Cigna — two insurers that pledged reform — only 16% said they’d actually seen requirements decrease.
6. For ASCs, the burden is growing, not shrinking. In 2024, 46% of ASC cases required prior authorization, up from 42% the year before — and only 24% of those authorizations were completed on the first attempt.
7. Insurers’ own finances help explain the squeeze. Seventy-three percent of health plans reported operating losses in 2025. Over the same period, 54% of revenue cycle leaders said claim denials are increasing, and 41% said at least 1 in 10 claims are now being rejected — the same dynamic Mr. Quigley described insurers using prior authorization to manage.
8. Washington’s AI-driven fix is facing bipartisan pushback. CMS’s WISeR (Wasteful and Inappropriate Service Reduction) pilot, which uses artificial intelligence to review Medicare claims, launched Jan. 1 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington and is set to run through 2031. The House Appropriations Committee voted June 9 to block its funding, and 31 House Democrats have asked CMS for pilot data, citing reports of denials and longer wait times. A report from Sen. Maria Cantwell, D-Wash., found authorization wait times in pilot states have grown two to four times longer — to 10 to 15 days, from one to two days before the program began.
9. States aren’t waiting on Washington. A Massachusetts law that took effect June 5 restricts prior authorization for roughly half of the state’s commercially insured residents, prohibiting it for emergency and urgent care, primary care, imaging after a cancer diagnosis, preventive services, maternity care and substance use disorder treatment.
10. One reform meant to ease the burden is under utilized. Gold-carding programs exempt physicians with strong approval track records from prior authorization altogether. But only 10% of physicians contract with health plans that offer one. In the meantime, practices complete an average of 39 prior authorizations per physician each week, spend 13 hours on the paperwork, and in 40% of cases employ staff whose job is dedicated to prior authorization alone.
KFF long-form article includes copious interviews, case stories, and source links.
Clipped here for length.
https://kffhealthnews.org/insurance/prior-authorization-insurance-denials-reform-pledge-year-later/
Insurers Hedge on Trump-Backed Pledge To Improve Denials Process
Lauren Sausser and Renuka Rayasam July 17, 2026
One year after the Trump administration announced that dozens of health insurers had signed a six-part pledge promising to reduce barriers to doctor-recommended care, some insurers now say they won’t implement all the promised initiatives.
Meanwhile, patients, their advocates, and clinicians say little has improved.
“It has never been this bad for patients,” said U.S. Rep. Greg Murphy (R-N.C.), a physician who co-chairs the GOP Doctors Caucus.
We Want To Hear Your Story.
Do you have experience with prior authorization you’d like to share with us for KFF Health News’ reporting? Click here to reach us.The overarching intent of the June 2025 pledge was to improve a controversial process called prior authorization, which regularly requires patients or someone on their medical team to seek approval from insurers before proceeding with treatment.
According to AHIP, the health insurance industry trade group, health plans have eliminated 6.5 million prior authorizations for patients — equal to an 11% reduction — since the announcement.
But critics remain skeptical. Sally Nix, a patient advocate who has a chronic disease, described the voluntary pledge as “performative.” And Murphy, who participated in the news conference with Health and Human Services Secretary Robert F. Kennedy Jr. announcing the pledge last year, said it has “no teeth.”
Voluntary insurer pledges rarely make things better for patients, said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University.
“In the absence of clear rules, policies, standards, and mandates,” she said, insurance companies are “going to do what makes sense for them to do financially.”
The Department of Health and Human Services did not respond to questions for this report. It isn’t clear how, or whether, the Trump administration is holding insurers accountable.
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