US Analysis Highlights Prior Authorization Burden Across Health Plans

Key Takeaways

• Prior authorization (PA) remains widespread across US health insurance programs, with reported denial rates ranging from 3.5% to 13% and higher rates for specialty and time-sensitive services.
• PA-related administrative costs exceed $90 billion annually, with most of the burden borne by health care providers and patients rather than payers.
• Among 7 proposed congressional reforms, electronic PA processing emerged as the weighted consensus recommendation after combining scored and stakeholder survey analyses.

PA remains a prominent component of US oncology care, but variation among payers and substantial administrative burden may affect timely access to treatment. A mixed-methods MBA health policy analysis evaluating PA practices across Medicare Advantage, Medicaid, and commercial insurance found broad PA use and identified electronic processing as the leading reform strategy based on combined scored and stakeholder survey analyses.

Prior Authorization Use and Administrative Burden

The analysis incorporated publicly available administrative data, peer-reviewed literature, federal reports, and a cross-sectional stakeholder survey. Researchers evaluated PA utilization, denial rates, administrative burden, and downstream effects across Medicare Advantage, Medicaid, and commercial insurance.

PA use was extensive across payers, with Medicare Advantage plans requiring authorization for most covered services. Reported denial rates ranged from 3.5% to 13%, with higher rates observed for specialty and time-sensitive services.

Administrative costs associated with PA exceeded $90 billion annually. According to the analysis, providers and patients shouldered most of the administrative costs associated with PA, rather than insurance payers. Previous studies included in the analysis also identified associations between PA restrictions and delayed initiation of cancer care and increased downstream acute care utilization.

Researchers examined 7 potential reforms proposed by Congress: electronic PA processes, automatic approvals, standardized appeals, expanded gold card eligibility, PA time limits, public reporting of denials and appeals, and regulation of artificial intelligence use in PA processing.

The stakeholder survey included 40 patients, clinicians, and insurance or administrative personnel with direct PA experience. Overall, 65% reported PA exposure as health care professionals, 42.5% as patients, and 12.5% as insurance or administrative workers, while 5% reported no direct PA experience. Categories were not mutually exclusive.

Almost all respondents reported negative impressions of PA, describing the process with terms including “frustrating” and “time-consuming.” Electronic processing and automatic approvals were identified as the most feasible and impactful approaches for improving efficiency and access.

Electronic Prior Authorization Emerges as Leading Reform Strategy

For oncology clinicians and payers, the findings highlight the administrative and access considerations surrounding PA requirements for high-cost and time-sensitive cancer therapies. Although PA is intended to support evidence-based utilization, the analysis identified substantial variation in denial rates and administrative burden across payers.

The findings also provide a comparison of several potential policy approaches to PA reform. Among the 7 strategies evaluated, electronic processing and automatic approvals received the strongest support from survey respondents for both feasibility and potential impact.

When the scored and survey analyses were combined, the weighted consensus favored a congressional mandate for electronic PA processing. The analysis concluded that PA reform should seek to improve timely access while maintaining evidence-based cancer care.

Reducing Prior Authorization Burden While Preserving Evidence-Based Care

Stakeholder responses reinforced concerns about the practical burden associated with PA. Nearly all survey participants reported negative impressions.

The authors conclude that PA remains a prominent feature of oncology care delivery, with substantial administrative burden and variation across payers. Electronic PA processing emerged as the weighted consensus reform, highlighting one potential approach for improving efficiency and timely access while preserving evidence-based cancer care.

Reference

Odia Y, Keegan-Strosser J, Marte JA. Prior authorization utilization, administrative burden, and implications for timely care. J Clin Oncol. 2026;44(16_suppl):e23035. doi:10.1200/JCO.2026.44.16_suppl.e2303