But this year, because of a new Medicare program, Curry has traveled a little more often.

In February, during one trip, he was told unexpectedly that he needed preapproval for the procedure. Then he went again a month or so later to get the injection, for a total of 10 hours on the road. His clinic wanted him to come in a third time, which they had never asked of him before. That appointment was “just to fill out a piece of paper to tell them how you feel again,” Curry said, so he hasn’t gone.

In January, Oklahoma became one of six states to begin a pilot program testing the use of preapprovals in traditional Medicare, the federal health insurance program for people 65 and older or with disabilities. Medicare had previously eschewed the practice — also known as prior authorization — which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions.

Epidurals like Curry’s are among 13 medical services subject to the new program because the Trump administration says they’re prone to fraud or misuse. Powered by artificial intelligence, the program — called the Wasteful and Inappropriate Service Reduction Model, or WISeR — is intended to save the federal government money and protect patients from potentially unsafe or unneeded care.

Yet early reviews from Oklahoma and the other pilot states — Arizona, New Jersey, Ohio, Texas, and Washington — suggest WISeR’s rollout has not been smooth. Patients, doctors, and other healthcare professionals who spoke with ºÚÁϳԹÏÍø News say the effort has created confusion, errors, long wait times, and stress. Some described the rollout as “horrendous” and say people enrolled in Medicare in the pilot states are now getting ensnared in the same red tape as those with private insurance.

One key concern is that it all happened too hastily. WISeR was and launched in mid-January.

That was “quicker than normal” for the federal government, said Todd Baker, who recently stepped down as CEO of the Ohio State Medical Association. Doctors “just sort of had to figure it out,” added Jeb Shepard, director of policy at the Washington State Medical Association.

Government contractors have also acknowledged the rapid pace. “We’ve had an aggressive rollout from the time of being notified to going live,” said Jeremy Friese, CEO of Humata Health, the vendor for Oklahoma. Tech executives servicing other states have said they were still adding features to their products in the spring.

Abe Sutton, director of the Center for Medicare and Medicaid Innovation, which is administering the program, didn’t comment on the rollout schedule. But he said in a statement that the goal of these reforms is to ensure that prior authorization is efficient, fast, and streamlined.

“The model aims to reduce inappropriate care without delaying appropriate care,” he said.

Mehmet Oz, the leader of the Centers for Medicare & Medicaid Services, that they were “rolling out some prior authorization on abused practices.”

“The purpose of these is not to deny care,” Oz continued. “It’s to make sure you get the care you need and deserve, not the care some unscrupulous doctor wants to use on you.”

Medicare has struggled in recent years with suspected fraud associated with particular services. The Department of Health and Human Services’ inspector general spending on skin substitutes, for example, had surged nearly 700% over two years, raising “major concerns about fraud, waste, and abuse.” Skin substitutes are among the currently subject to review under WISeR.

The program also imposes prior authorization requirements for kyphoplasty, a surgery for spinal fractures, which a report by the Medicare Payment Advisory Commission .

Sutton acknowledged, however, that “the percentage of providers committing waste, fraud, and abuse is small.”

Consumers and clinicians largely detest prior authorization. Even as federal health officials test the process for Medicare, the Trump administration is for those with private insurance. According to a conducted in January, 69% of insured adults consider prior authorization a burden for care.

Through WISeR, doctors and their staff log in to online portals to submit medical records that justify the procedures. Using artificial intelligence, the systems quickly approve applications that meet the program’s criteria, Friese, Humata’s chief executive, told ºÚÁϳԹÏÍø News. He said there is an “immediate yes” in 88% of cases for which clinical data supports an approval.

CMS has touted the process as one in which decisions are returned within 72 hours. After that, clinicians receive a “universal tracking number,” which allows them to schedule the procedure and get paid. In practice, however, participants say the process is anything but easy.

The University of Washington’s medical system alone had nearly 100 patients waiting earlier this year for epidural injections due to WISeR-related delays, from the office of U.S. Sen. Maria Cantwell (D-Wash.) that drew on hospital association data. “Now, patients are subject to delays or denials which did not exist prior to the WISeR Model,” the report said.

Curry, the Oklahoma cattle farmer, said he might go to Kansas for future treatments to avoid the approval process. Dorota Gribbin, a New Jersey-based physical medicine and rehabilitation physician, said that by the time authorization came for one of her patients who needed a back pain procedure, the patient had gone to the hospital for more expensive care.

Jennifer Valle, a precertification and insurance supervisor at Clinical Radiology of Oklahoma, said when it comes to kyphoplasties, there has been a lot of “nitpicking” from reviewers. Other times, information her practice provides to CMS gets overlooked, she said, and reviewers ask for imaging that’s already in the file.

Claims with no problems are supposed to be paid within 15 days, said James Webb, a musculoskeletal radiologist in Tulsa, Oklahoma, who has also been frustrated by the prior approval and reimbursement process for kyphoplasties. “Six- to eight-week delays is what we’ve been seeing,” he said.

“It’s been horrendous,” said Jerry Sobel, a Phoenix-area pain management doctor. “Right from the beginning, there seemed to be no organization.” Sobel said that as of May, he hadn’t gotten paid by Medicare for nine epidurals.

“We continuously monitor operations and work closely with stakeholders to address questions and improve the provider experience,” said Sundar Subramanian, the CEO of Zyter, which has the contract for Arizona.

During an April webinar, another Zyter executive acknowledged a large backlog in payments stretching to January. Those backlogs “are currently being resolved,” Medicare’s Sutton said, without providing further detail.

When asked about other issues — including what doctors suspect are AI-driven errors — Medicare’s Sutton said the agency appreciates “feedback on provider experience.” It will be used “to help providers better understand WISeR processes,” he said.

Although CMS vendors say humans make the final decisions on approvals, doctors and their staffs believe artificial intelligence is playing a large role in the process and that denials are sometimes the result of AI hallucinations that garble or make up information.

One Arizona doctor, who wasn’t authorized by his practice to speak, recalled a denial saying his patient wasn’t eligible for procedures in the thoracic region, or mid-back. The patient needed an injection to the neck. Webb, the Oklahoma radiologist, documented four times that a patient lacked numbness, and yet his WISeR application was still denied, citing numbness, which, in the reviewer’s interpretation, would rule out the spinal surgery procedure.

Friese, Humata’s CEO, said he hasn’t heard about any AI hallucinations.

The process is also raising government costs. With more rejections, more appeals are being filed with Medicare’s administrative contractors. The government pays the contractors to handle the appeals, and Medicare’s Sutton acknowledged that the agency has “accounted for potential changes in the volume of Medicare appeals because of the WISeR program and its associated costs.”

Eighty-four percent of commercial insurers already use AI tools, according to a survey released in 2025 by the National Association of Insurance Commissioners, though they have consistently said AI isn’t used to deny prior authorization requests.

Its use in Medicare risks introducing friction and frustration into the program — and piling costs onto its beneficiaries. Prior authorization saves money for insurers partly by making patients pay a price in wait times and inconvenience, said Miranda Yaver, a University of Pittsburgh health policy researcher studying the technique.

“People will end up getting ensnared in a lot of red tape, having to be on hold, and getting rerouted,” she said. She often wonders whether prior authorization simply shifts costs to patients and doctors, rather than saving them.

Some doctors involved in Medicare’s prior authorization experiment believe it will inevitably expand beyond a few services officials in Washington consider fraud-prone.

“Everybody knows that if this pilot project works, it will be prior auth for basically all procedures,” said Mary Clarke, a family practice physician in Stillwater, Oklahoma. “If they can show that they can save money, then that’s going to be extrapolated and rolled out to other procedures and multiple other things in other states.”

When asked whether CMS is considering expansion of its prior authorization pilot, Sutton said in his statement that there are “currently no changes” considered for the list of services subject to the WISeR program, “but CMS continues to assess whether any changes are warranted.”

Do you have an experience with prior authorization you’d like to share? to tell ºÚÁϳԹÏÍø News your story.

ºÚÁϳԹÏÍø News Southern correspondent Lauren Sausser contributed to this report.

This <a target="_blank" href="/medicare/medicare-ai-prior-authorization-wiser-delays-errors/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Six months after a West Virginia man died following a protracted battle with his health insurer over doctor-recommended cancer care, the state’s Republican governor signed a bill intended to curb the harm of insurance denials.

West Virginia’s Public Employees Insurance Agency enrolls nearly 215,000 people — state workers, as well as their spouses and dependents. The new law, which will take effect June 10, will allow plan members who have been approved for a course of treatment to pursue an alternative, medically appropriate treatment of equal or lesser value without the need for another approval from the state-based health plan.

“This legislation is rooted in a simple principle: if a treatment has already been approved, patients should be able to pursue a medically appropriate alternative without being forced to start the process over again — especially when it does not cost more,” Gov. Patrick Morrisey said in a statement after signing the bill into law on March 31.

“This is about common sense, compassion, and trusting patients and their doctors to make the best decisions for their care,” he said.

Delegate Laura Kimble, the Republican from Harrison County who introduced the legislation, told ºÚÁϳԹÏÍø News the measure offers “a rational solution” for patients facing “the most irrational and chaotic time of their lives.”

From Arizona to Rhode Island, at least half of all state legislatures have taken up bills this year related to prior authorization, a process that requires patients or their medical team to seek approval from an insurer before proceeding with care. These state efforts come as patients across the country await relief from prior authorization hurdles, as promised by dozens of major health insurers in a pledge announced by the Trump administration last year.

The West Virginia law was inspired by Eric Tennant, a coal-mining safety instructor from Bridgeport who died on Sept. 17 at age 58. In early 2025, the Public Employees Insurance Agency of a $50,000 noninvasive cancer treatment, called histotripsy, that would have used ultrasound waves to target, and potentially shrink, the largest tumor in his liver. His family didn’t expect the procedure to eradicate the cancer, but they hoped it would buy him more time and improve his quality of life. The insurer said the procedure wasn’t medically necessary and that it was considered “experimental and investigational.”

Becky Tennant, Eric’s widow, told members of a West Virginia House committee in late February that she submitted medical records, expert opinions, and data as part of several attempts to appeal the denial. She also reached out to “almost every one of our state representatives,” asking for help.

Nothing worked, she told lawmakers, until ºÚÁϳԹÏÍø News and NBC News got involved and posed questions to the Public Employees Insurance Agency about Eric’s case. Only then did the insurer reverse its decision and approve histotripsy, Tennant said.

“But by then, the delay had already done its damage,” she said.

Within one week of the reversal in late May, Eric Tennant was hospitalized. His health continued to decline, and by midsummer he was no longer considered a suitable candidate for the procedure. “The insurance company’s decision did not simply delay care. It closed doors,” his wife said.

Had the new law been in effect, Kimble said, Tennant could have undergone histotripsy without preapproval, because it was a less expensive alternative to chemotherapy, which his insurer had already authorized. The bill was passed unanimously by the state legislature in March.

U.S. health insurers argue that most prior authorization requests are quickly, if not instantly, approved. AHIP, the health insurance industry trade group, says prior authorization in preventing potential harm to patients and reducing unnecessary health care costs. But denials and delays tend to affect patients who need expensive, time-sensitive care, .

The practice has come under intense scrutiny in recent years, particularly after the in New York City in late 2024. Americans rank prior authorization as their biggest burden when it comes to getting health care, according to a by KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Samantha Knapp, a spokesperson for the West Virginia Department of Administration, would not answer questions about the law’s financial impact on the state. “We prefer to avoid any speculation at this time regarding potential impact or actions,” Knapp said.

In a fiscal note attached to the bill, Jason Haught, the Public Employees Insurance Agency’s chief financial officer, said the law would cost the agency an estimated $13 million annually and “cause member disruption.”

West Virginia isn’t an outlier in targeting prior authorization. By late 2025, 48 other states, in addition to the District of Columbia and Puerto Rico, already had some form of a prior authorization law — or laws — on the books, according to a by the National Association of Insurance Commissioners.

Many states have set up “gold carding” programs, which allow physicians with a track record of approvals to bypass prior authorization requirements. Some states establish a maximum number of days insurance companies are allowed to respond to requests, while others prohibit insurance companies from issuing retrospective denials after a service has already been preauthorized. There are also a crop of new state laws seeking to regulate the use of artificial intelligence in prior authorization decision-making.

Meanwhile, prior authorization bills introduced this year across the country, including in Kentucky, Missouri, and New Jersey, have been supported by politicians from both parties.

“Republicans in conservative states see health care as a vulnerability for the midterm elections, and so, unsurprisingly, you’ll see some action on this,” said Robert Hartwig, a clinical associate professor of risk management, insurance, and finance at the University of South Carolina. “They realize that they’re not really going to get much action at the federal level given the degree of gridlock we’ve already seen.”

Last summer, the Trump administration announced a pledge signed by dozens of health insurers vowing to reform prior authorization. The insurers promised to reduce the scope of claims that require preapproval, decrease wait times, and communicate with patients in clear language when denying a request.

Consumers, patient advocates, and medical providers that companies will follow through on their promises.

Becky Tennant is skeptical, too. That’s why she advocated for the West Virginia bill.

“Families should not have to beg, appeal, or go public just to access time-sensitive care,” she told lawmakers. Tennant, who sees the bill’s passage as bittersweet, said she thought her husband would have been proud.

During Eric’s final hospital stay, Tennant recalled, right before he was discharged to home hospice care, she asked him whether he wanted her to keep fighting to change the state agency’s prior authorization process.

“‘Well, you need to at least try to change it,’” she recalled her husband saying. “‘Because it’s not fair.’”

“I told him I would keep trying,” she said, “at least for a while. And so I am keeping that promise to him.”

NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.

Do you have an experience with prior authorization you’d like to share? to tell ºÚÁϳԹÏÍø News your story.

This <a target="_blank" href="/health-industry/prior-authorization-insurance-delays-coverage-denials-state-laws-west-virginia/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

That’s why Ekirch, 31, of Henrico, Virginia, was stunned when she learned Anthem would finally have to pay for life-changing medical treatment.

For two years, she had battled the company to cover blood plasma infusions called intravenous immunoglobulin, or IVIG. The treatment has been shown, in some cases, to improve symptoms associated with small-fiber neuropathy, a condition that makes Ekirch’s limbs feel like they’re on fire.

But Anthem had repeatedly denied coverage for IVIG, which costs about $10,000 per infusion. Then, in February, an external review of her case conducted for the Virginia Bureau of Insurance overturned Anthem’s denial. It meant her parents would no longer need to withdraw money from her father’s retirement savings to pay out-of-pocket. Already, they’d spent about $90,000.

“My mom was sobbing. My dad was on his knees, sobbing. I don’t think I’ve ever seen him cry like that,” said Ekirch, describing her parents’ reaction to the reversal.

“I think I’m in shock from it all,” she said.

In a prepared statement, Stephanie DuBois, a spokesperson for Anthem Blue Cross and Blue Shield, said IVIG did not “align with our evidence-based standards.” But she said the company respects “the external reviewer’s decision” to overturn the denial.

Meanwhile, each year millions of patients like Ekirch continue to face denials through the prior authorization process, which requires many patients or their doctors to seek preapproval from health insurers before proceeding with medical care. And despite promises of reform from insurance companies, denials remain a frustrating hallmark of the American health care system.

Last June, Trump administration officials announced in a press conference that health insurance leaders had pledged to simplify prior authorization by taking steps such as “” subject to preapproval. The insurers also promised faster turnaround times and “clear, easy-to-understand explanations” of their decisions.

Yet in February, when ºÚÁϳԹÏÍø News contacted more than a dozen major insurers that signed the pledge, half of them failed to provide specifics about health care services for which they no longer require prior authorization.

A said the industry remains committed to the effort. But physicians, consumers, and patient advocates are pessimistic about the insurers’ willingness to follow through with these voluntary changes.

“They have no desire to do what’s in the best interest of the patient if it’s going to hurt their pockets,” said Matt Toresco, CEO of Archo Advocacy, a patient advocacy and consulting company.

“In the insurance world, the fiduciary responsibility is not to the patient,” he said. “It’s to the Street,” he said, referring to Wall Street.

Meaningful Change?

The Department of Health and Human Services did not respond to questions for this article. The few updates the federal government has issued since June on prior authorization reform include a about ensuring clinicians can submit requests electronically.

AHIP, the health insurer trade group that issued the January press release, did not provide information about specific treatments, codes, medications, or procedures that its members have released from prior authorization since signing the pledge.

“We will have additional progress updates coming out later this spring,” said Kelly Parsons, a spokesperson for the Blue Cross Blue Shield Association, which represents 33 independent Blue Cross and Blue Shield companies. She also offered no specifics.

Blue Cross and Blue Shield companies that cover patients in Alabama, Arkansas, Iowa, Michigan, Pennsylvania, South Carolina, South Dakota, and Tennessee either did not respond to questions for this article or deferred to the Blue Cross Blue Shield Association.

By contrast, other insurers cited specific examples of change.

Aetna CVS Health began “bundling” prior authorizations for musculoskeletal procedures, as well as for lung, breast, and prostate cancer patients, spokesperson Phil Blando said. This practice allows providers to file one authorization request for a patient’s treatment instead of several.

And Humana removed prior authorization requirements for “diagnostic services across colonoscopies,” among other changes, spokesperson Mark Taylor said.

UnitedHealthcare, which came under intense scrutiny for its use of prior authorization following the of one of its executives in late 2024, removed prior authorization requirements on Jan. 1 for “certain nuclear imaging, obstetrical ultrasound and echocardiogram procedures,” among other changes, spokesperson Matthew Rodriguez said.

Yet some health care insiders doubt these changes will amount to much.

“Insurers have made similar promises before and failed to deliver meaningful change,” said Bobby Mukkamala, president of the American Medical Association, which represents U.S. physicians and medical students.

In 2018, , including AHIP and the Blue Cross Blue Shield Association, announced a partnership “to identify opportunities to improve the prior authorization process.” Yet, in response to the June pledge, the process remains “costly, inefficient, opaque, and too often hazardous for patients.”

“Transparency is essential so everyone can see whether real reforms are happening,” he told ºÚÁϳԹÏÍø News.

Curbed Enthusiasm

Prior authorization may be getting more political attention, but data shows patients — particularly those with chronic conditions that require ongoing medical treatment — continue to face barriers to doctor-recommended care.

Among patients in that group, 39% said prior authorization is “the single biggest burden” in receiving care, according to a by KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

I was fighting to survive, and then I was fighting to convince someone that I deserved to survive.

Anna Hocum

That’s true for Payton Herres, 25, of Dayton, Ohio, who in 2012 received a heart transplant, which requires her to take an antirejection prescription medication for the rest of her life.

But last year, she said, Anthem denied coverage for the expensive drug. She’d been taking it for more than 10 years.

“I’ve been with Anthem my entire life, and then, all of a sudden — I don’t know what happened — they just started denying me over and over,” she said. “I almost ran out of medication.”

DuBois, the Anthem spokesperson, confirmed the company has approved the medication. It had not taken Herres’ treatment history into account when it denied coverage for the drug, DuBois said.

But Herres said the company will require her to obtain a new authorization for the medication in September.

“Are they going to deny other things, too?” she asked. “I hope I don’t have to keep fighting like this for the rest of my life.”

Anna Hocum, 25, is preparing for a similar fight. In 2024 and 2025, her insurer repeatedly denied coverage for expensive treatment used to slow the progression of a rare genetic condition that destroys her lung function.

“I just thought I was going to die,” said Hocum, of Milwaukee. “I was fighting to survive, and then I was fighting to convince someone that I deserved to survive.”

Like with Ekirch, Hocum’s parents paid while they waited for her insurance company to overturn the initial denials. Friends and family donated more than $30,000 through a GoFundMe campaign to help defray the costs.

Then last spring, Hocum said, her insurer reversed the denial without an apparent explanation. But the approval is valid for only 12 months, so she will need another prior authorization approval this year.

“It is scary,” she said. “It’s not guaranteed that it’ll be accepted.”

They fought me tooth and nail every step of the way, to the point that they made my life a living hell.

Sheldon Ekirch

Even though it’s a “huge relief” that Anthem is now obligated to cover Ekirch’s treatment, her mother doesn’t know if or how the family will recoup the money it has already paid.

In a letter to Ekirch confirming the external reviewer’s decision, Anthem explained that the authorization would be valid for a year beginning on Sept. 25, 2025. “We are pleased we can provide a favorable response in this case,” a grievance and appeals analyst for Anthem wrote.

Ekirch said the letter highlighted the company’s hypocrisy.

“They act as though they are a benevolent organization doing me a favor.” In reality, she said, “they fought me tooth and nail every step of the way, to the point that they made my life a living hell.”

Now, Ekirch’s access to IVIG may be in jeopardy again. Her COBRA coverage through Anthem expires in late March. In April, she will need to transition to a new insurance plan — and she’s bracing herself for another round of prior authorization.

“I just am so afraid that I don’t have the strength to go through and do what it takes,” Ekirch said, “to fight this battle again.”

Do you have an experience with prior authorization you’d like to share? to tell ºÚÁϳԹÏÍø News your story.

This <a target="_blank" href="/health-care-costs/prior-authorization-insurer-pledge-awaiting-reforms-patients-families-bills/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

A woman with multiple sclerosis wanted to be able to walk up the stairs at home without losing her balance. Her doctor prescribed medicine that helped, but then approval from her insurance plan for the drug expired.

“Why do I need a prior authorization for something that I am already prior-authorized to take? If my doctor says that they want me on a medication, why does my insurance have another say in that?”

— Jaclyn Mayo, Lunenburg, Massachusetts

Jaclyn Mayo has multiple sclerosis, an autoimmune disease that damages the nervous system and can mess with coordination and balance. To get steadier on her feet, Mayo had been trying to lose weight: A lighter body puts less stress on the joints and leads to greater flexibility.

After Mayo didn’t have much luck with diet and exercise, her physician prescribed Zepbound, a GLP-1 weight loss medication that suppresses appetite.

“It was really helping me,” she said. “I could go up and down stairs and not feel like I was going to fall.”

As a happy bonus, the GLP-1 seemed to ease other MS symptoms for Mayo: She started sleeping through the night, and the frequent numbness in her hands went away.

After being on Zepbound for seven months, she fell into an insurance pitfall: prior authorization.

In August, her pharmacy wouldn’t refill her prescription, and it wasn’t clear why.

She called her pharmacist, then her doctor’s office, the pharmacist again, then her insurance company. After speaking with the insurance company’s pharmacy benefit manager — a third-party company that oversees prescription drug plans for insurers — Mayo figured out that the advance approval her insurer had granted for the drug, known as prior authorization, had expired.

Insurers require prior authorizations for certain treatments or tests, especially costly ones. When they do, your doctor has to make the preauthorization request to your insurance company, explaining why you need the treatment. Next, the insurer decides if it agrees that the care is medically necessary and if it will pay for it.

Mayo had been taking the weight loss medicine for less than a year and didn’t understand why a new prior authorization was needed so soon. She said she never got a letter or email notifying her that the clock had run out on her first prior authorization. As someone with a chronic illness, Mayo said, she keeps close track of her medical paperwork. She feels like she did everything right, which, she said, made the situation especially infuriating.

Her doctor submitted the necessary paperwork then found out the new approval would take seven to 10 business days.

At this point, Mayo had been off her medication for two weeks. Her sleep was getting worse, and the tingling numbness in her hands returned. So she asked that her prior authorization be expedited, only to learn that her doctor, not Mayo, would need to make the request for an urgent review.

“That red tape was completely avoidable,” she said. “And all that they needed to do was communicate clearly to me. And then I could have continued my medication without delays. But they didn’t.”

Why Insurers Want Prior Authorization

Doctors are often frustrated by the prior authorization process, but insurers argue it helps keep costs down.

AHIP, the insurer trade group formerly known as America’s Health Insurance Plans, declined an interview request. But in an emailed statement, it said that prior authorizations are an important safeguard that helps ensure patients receive safe, evidence-based care and keeps coverage affordable.

In a , the American Medical Association, which represents physicians, said the way health plans use prior authorizations is “opaque and overly complex,” creating delays in care and greater administrative burden.

Patients are also frustrated. A found that 1 in 3 insured adults call prior authorizations a “major burden” to accessing health care.

Mayo hit preauthorization hurdles likely because her physician prescribed a GLP-1, an . The more costly the treatment, the greater the scrutiny, said of the University of Pittsburgh, who studies health politics and administrative burdens within the insurance system.

Issues with prior authorizations are common. Policymakers could standardize how insurance companies evaluate prior authorization requests to prevent more Americans from experiencing medical disruptions, Yaver said.

“It’s a solvable problem, if we have the will and the political conditions are ripe. I don’t think that they are at this particular moment,” she said.

Here’s what to know about getting prior authorization requests approved in a timely manner.

1. Find out when your prior authorization expires.

Individual insurance companies, and even the individual plans within those companies, often have different policies for prior authorizations.

“As you can imagine, that becomes an absolute nightmare,” said physician David Aizuss, chair of the AMA’s board of trustees.

While expensive treatments are more likely to be targeted for prior authorization review, Aizuss said it also happens for low-cost generic drugs.

To figure out how long your prior authorization lasts, reach out to customer service at your insurance company or pharmacy benefit manager, whichever handles your plan’s prior authorizations.

2. Don’t procrastinate.

Getting a prior authorization isn’t always quick, so build in time for things to go wrong.

It took Mayo nearly three weeks to sort out the prior authorization issue for her GLP-1 prescription. She made the initial refill request about a week before her medication was set to run out and ended up without the drug for over two weeks.

3. Ask your doctor to request an expedited review.

As you wait for your prior authorization to go through, your doctor might not know how much medication you have left, or that your health may be declining. You can have your doctor request an expedited review. Though, as Mayo found, insurance companies and PBMs won’t always volunteer that as an option.

When an expedited review is appropriate is up for interpretation, said , director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

“No one knows the specifics of what urgent means,” she said.

require that urgent requests made by people with employer-based plans be decided within 72 hours. And, on Jan. 1, a took effect that creates a similar requirement for all Medicare Advantage, Medicaid, and Children’s Health Insurance Program plans. However, this rule doesn’t apply to medications.

4. Consider other treatment options.

When Mayo’s doctor first suggested that she try a GLP-1, approval for the specific medication was taking a long time. When it became clear the request would probably be denied, the doctor canceled that initial request and put in a prior authorization request for a different brand of GLP-1, Zepbound. It was approved.

Ask your doctor about treatment alternatives. Health plans have different formularies — lists of medicines that are routinely approved. It might be easier to switch medications than to fight to get your health plan to approve coverage.

But be aware that your insurance company might change your health plan’s drug formulary anytime and require you to get a new prior authorization.

5. Don’t be afraid to appeal.

Submit an appeal, even if you’re worried you’ll lose. Yaver said that, based on the research set to be published in , Coverage Denied: How Health Insurers Drive Inequality in the United States, people who appeal a prior authorization or claims denial win about half the time.

First figure out where to send your appeal. Usually, it’s an insurance company, but if the treatment you need is medication, it may be a PBM.

Include detailed records in your appeal.

If you’re trying to get approval for a specific medication, Yaver said, send documentation showing that you tried other medications or treatments that didn’t work. This helps make your case and can speed up the process.

“I actually just went through a prior authorization for my migraine drug,” Yaver said. “It actually went through very quickly.”

Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and ºÚÁϳԹÏÍø News.

This <a target="_blank" href="/health-industry/health-care-helpline-prior-authorization-insurance-companies-plans-drugs-pbms-tips/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

“It’s good to be home,” he said after one hospital stay in early June, “yet I’m tired and ready to get on with things.”

In 2023, Tennant, of Bridgeport, West Virginia, was diagnosed with cholangiocarcinoma, a rare cancer of the bile ducts that had spread throughout his body.

None of the initial treatments prescribed by his doctors had eradicated the cancer. But a glimmer of hope came in early 2025, when Tennant was recommended for histotripsy, a relatively new procedure that would use ultrasound waves to target, and potentially destroy, the largest tumor in his body — in his liver.

“My dad was a little nervous because it was something new, but it definitely gave us some hope that he would be around a little bit longer,” said Tennant’s daughter, Amiya.

There was just one hitch: His insurer wouldn’t pay for it.

Tennant, 58, died of cancer on Sept. 17. His story illustrates how a bureaucratic process called prior authorization can devastate patients and their families.

It’s infeasible to count the people harmed by this , which, by delaying or denying care, helps drive health insurers’ profits. No government agency or private group tracks such data.

That said, ºÚÁϳԹÏÍø News has heard from hundreds of patients in recent years who claim that they or someone in their family has been harmed by prior authorization. More than 1 in 4 physicians in December said that prior authorization had led to a serious adverse event for a patient in their care. And 8% responded that prior authorization led to a disability, birth defect, or death.

In June, the Trump administration announced a pledge, signed by dozens of private insurers, to streamline prior authorization, which often requires patients or their medical teams to ask insurers for permission before proceeding with many types of care. It remains unclear when patients can expect to see improvement.

The commitments “depend on the full cooperation of the private insurance sector” and will “take time to achieve their full effect,” said Andrew Nixon, a spokesperson for the Department of Health and Human Services. But the pledge exists, he said, “to prevent tragic deaths like Eric’s from occurring at the hands of an inefficient system.”

Chris Bond, a spokesperson for AHIP, a health insurance industry trade group, said he could not speak to any specific insurer’s prior authorization policies. Broadly, though, he said prior authorization “acts as a guardrail” to make sure medicines and treatments are not used inappropriately.

At the same time, he said, insurers recognize that patients can be frustrated when their doctor-recommended care is denied. That’s why “there is a dedicated effort across the industry to make the process more straightforward, faster, and simpler for patients and providers,” Bond said.

In the meantime, the process continues to take its toll on people like Eric Tennant, whose grave diagnoses often require expensive health care services.

“Eric is gone,” his widow, Becky, said. “He’s not coming back.”

Tennant was a safety instructor for the West Virginia Office of Miners’ Health Safety and Training and insured by the state’s Public Employees Insurance Agency, which contracts with UnitedHealthcare to administer benefits for state employees, their spouses, and dependents.

In February and March, UnitedHealthcare, the Public Employees Insurance Agency, and an outside reviewer issued a series of denials that concluded Eric’s benefits would not cover histotripsy, claiming the treatment was not medically necessary. Becky Tennant estimated the procedure would cost the family about $50,000 out-of-pocket.

Although the treatment wasn’t guaranteed to work, it was worth a shot, the Tennants thought, so they considered withdrawing money from their retirement savings. But then, in May, after ºÚÁϳԹÏÍø News and NBC News posed a series of questions to UnitedHealthcare and the Public Employees Insurance Agency about Eric’s case, the agency reversed course. PEIA decided to cover his treatment.

Notably, the agency contacted ºÚÁϳԹÏÍø News about the approval hours before it notified the Tennant family of the decision.

But the approval came too late. Eric was hospitalized in late May and prescribed medication that prevented him from undergoing histotripsy at that time. His family held out hope that his health would improve and he would qualify for the procedure that summer.

In July, they took a family vacation to Marco Island, Florida. It would be their last. Two days after they returned home, a scan revealed Eric’s cancer had continued to spread. Histotripsy was out of the question.

“I’m sad for what we will miss out on,” Becky said. “I’m sad at the unfairness of it.”

She said if Eric had been able to undergo histotripsy in February, as originally recommended by his doctor, it might have destroyed the tumor in his liver that ultimately killed him.

“We’ll never know. That’s the thing. Any lawyer for the insurance will say, ‘Well, you don’t know it would have helped.’ No. You took that chance away from us,” she said.

In October, Samantha Knapp, a spokesperson for the West Virginia Department of Administration, told ºÚÁϳԹÏÍø News that the Public Employees Insurance Agency has not changed its policies related to prior authorization for histotripsy and continues to follow UnitedHealthcare’s guidelines.

UnitedHealthcare declined to answer questions for this article.

On Sept. 17, in a hospice bed set up in their dining room, Eric was surrounded by his family and their dogs as he died. Becky held his hand as his heart rate began to drop.

“He wasn’t afraid to die, but he didn’t want to die,” she said. “And you could tell the last day that he was fighting it big time.”

At the very end, she whispered in his ear: “You know I love you. You have been the best husband and the best dad, and you’ve always taken such good care of us,” Becky recalled.

And then, she said, he gasped. His eyebrows seemed to shoot up in wonder. During his last moment alive, she said, he smiled.

“The look on his face was pure, total amazement,” she said. “I still can’t believe he’s not here.”

Do you have an experience with prior authorization you’d like to share? to tell ºÚÁϳԹÏÍø News your story.

This <a target="_blank" href="/health-industry/prior-authorization-denials-cancer-treatment-west-virginia-death/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

She didn’t notice the tiny bug until Monday, when her calf muscle began to feel sore. She made an appointment that morning with a telehealth doctor — one recommended by her health insurance plan — who prescribed a 10-day course of doxycycline to prevent Lyme disease and strongly suggested she be seen in person. So, later that day, she went to a walk-in clinic near her home in Brunswick, Maine.

And it’s a good thing she did. Clinic staffers found another tick on her body during the same visit. Not only that, one of the ticks tested positive for Lyme, a bacterial infection that, if untreated, can  affecting the nervous system, heart, and joints. Clinicians prescribed a stronger, single dose of the prescription medication.

“I could have gotten really ill,” Kovitch said.

But Kovitch’s insurer denied coverage for the walk-in visit. Its reason? She hadn’t obtained a referral or preapproval for it. “Your plan doesn’t cover this type of care without it, so we denied this charge,” a document from her insurance company explained.

Health insurers have long argued that prior authorization — when health plans require approval from an insurer before someone receives treatment — reduces waste and fraud, as well as potential harm to patients. And while insurance denials are often associated with high-cost care, such as cancer treatment, Kovitch’s tiny tick bite exposes how prior authorization policies can apply to treatments that are considered inexpensive and medically necessary.

Pledging To Fix the Process

The Trump administration announced this summer that dozens of private health insurers agreed to make sweeping changes to the prior authorization process. The pledge includes releasing certain medical services from prior authorization requirements altogether. Insurers also agreed to extend a grace period to patients who switch health plans, so they won’t immediately encounter new preapproval rules that disrupt ongoing treatment.

Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said during a June press conference that some of the changes would be in place by January. But, so far, the federal government has offered few specifics about which diagnostic codes tagged to medical services for billing purposes will be exempt from prior authorization — or how private companies will be held accountable. It’s not clear whether Lyme disease cases like Kovitch’s would be exempt from preauthorization.

Chris Bond, a spokesperson for AHIP, the health insurance industry’s main trade group, said that insurers have committed to implementing some changes by Jan. 1. Other will take longer. For example, insurers agreed to answer 80% of prior authorization approvals in “real time,” but not until 2027.

Andrew Nixon, a spokesperson for the U.S. Department of Health and Human Services, told ºÚÁϳԹÏÍø News that the changes promised by private insurers are intended to “cut red tape, accelerate care decisions, and encourage transparency,” but they will “take time to achieve their full effect.”

Meanwhile, some health policy experts are skeptical that private insurers will make good on the pledge. This isn’t the first time major health insurers have vowed to reform prior authorization.

, president of the American Medical Association, that the promises made by health insurers in June to fix the system are “nearly identical” to those the insurance industry .

“I think this is a scam,” said Neal Shah, author of the book “.”

Insurers signed on to President Donald Trump’s pledge to ease public pressure, Shah said. Collective outrage directed at insurance companies was particularly intense following the killing of UnitedHealthcare CEO Brian Thompson in December. Oz specifically said that the pledge by health insurers was made in response to “violence in the streets.”

Shah, for one, doesn’t believe companies will follow through in a meaningful way.

“The denials problem is getting worse,” said Shah, who co-founded , a company that helps patients appeal insurance denials by using artificial intelligence. “There’s no accountability.”

Cracking the Case

Kovitch’s bill for her clinic appointment was $238, and she paid for it out-of-pocket after learning that her insurance company, Anthem, didn’t plan to cover a cent. First, she tried appealing the denial. She even obtained a retroactive referral from her primary care doctor supporting the necessity of the clinic visit.

It didn’t work. Anthem again denied coverage for the visit. When Kovitch called to learn why, she said she was left with the impression that the Anthem representative she spoke to couldn’t figure it out.

“It was like over their heads or something,” Kovitch said. “This was all they would say, over and over again: that it lacked prior authorization.”

Jim Turner, a spokesperson for Anthem, later attributed Kovitch’s denials to “a billing error” made by MaineHealth, the health system that operates the walk-in clinic where she sought care. MaineHealth’s error “resulted in the claim being processed as a specialist visit instead of a walk-in center/urgent care visit,” Turner told ºÚÁϳԹÏÍø News.

He did not provide documentation demonstrating how the billing error occurred. Medical records supplied by Kovitch show MaineHealth coded her walk-in visit as “tick bite of left lower leg, initial encounter,” and it’s not clear why Anthem interpreted that as a specialist visit.

After ºÚÁϳԹÏÍø News contacted Anthem with questions about Kovitch’s bill, Turner said that the company “should have identified the billing error sooner in the process than we did and we apologize for the confusion this caused Ms. Kovitch.”

Caroline Cornish, a spokesperson for MaineHealth, said this isn’t the only time Anthem has denied coverage for patients seeking walk-in or urgent care at MaineHealth. She said Anthem’s processing rules are sometimes misapplied to walk-in visits, leading to “inappropriate denials.”

She said these visits should not require prior authorization and Kovitch’s case illustrates how insurance companies often use administrative denials as a first response.

“MaineHealth believes insurers should focus on paying for the care their members need, rather than creating obstacles that delay coverage and risk discouraging patients from seeking care,” she said. “The system is too often tilted against the very people it is meant to serve.”

Meanwhile, in October, Anthem sent Kovitch an updated explanation of benefits showing that a combination of insurance company payments and discounts would cover the entire cost of the appointment. She said a company representative called her and apologized. In early November, she received her $238 refund.

But she recently found out that her annual eye appointment now requires a referral from her primary care provider, according to new rules laid out by Anthem.

“The trend continues,” she said. “Now I am more savvy to their ways.”

This <a target="_blank" href="/health-care-costs/prior-authorization-walk-in-clinic-tick-bite-coverage-denial/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The pilot program, designed to weed out wasteful, “low-value” services, amounts to a federal expansion of an unpopular process called prior authorization, which requires patients or someone on their medical team to seek insurance approval before proceeding with certain procedures, tests, and prescriptions. It will affect Medicare patients, and the doctors and hospitals who care for them, in Arizona, Ohio, Oklahoma, New Jersey, Texas, and Washington, starting Jan. 1 and running through 2031.

The move has raised eyebrows among politicians and policy experts. The traditional version of Medicare, which covers adults 65 and older and some people with disabilities, has mostly eschewed prior authorization. Still, it is widely used by private insurers, especially in the Medicare Advantage market.

And the timing was surprising: The pilot was , just days after the Trump administration unveiled a voluntary effort by private health insurers to revamp and reduce their own use of prior authorization, which causes care to be “significantly delayed,” said Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services.

“It erodes public trust in the health care system,” Oz told the media. “It’s something that we can’t tolerate in this administration.”

But some critics, like Vinay Rathi, an Ohio State University doctor and policy researcher, have accused the Trump administration of sending mixed messages.

On one hand, the federal government wants to borrow cost-cutting measures used by private insurance, he said. “On the other, it slaps them on the wrist.”

Administration officials are “talking out of both sides of their mouth,” said Rep. Suzan DelBene, a Washington Democrat. “It’s hugely concerning.”

Patients, doctors, and other lawmakers have also been critical of what they see as delay-or-deny tactics, which can slow down or block access to care, causing irreparable harm and even death.

“Insurance companies have put it in their mantra that they will take patients’ money and then do their damnedest to deny giving it to the people who deliver care,” said Rep. Greg Murphy, a North Carolina Republican and a urologist. “That goes on in every insurance company boardroom.”

Insurers have long argued that prior authorization reduces fraud and wasteful spending, as well as prevents potential harm. Public displeasure with insurance denials dominated the news in December, when the shooting death of UnitedHealthcare’s CEO led many to anoint his alleged killer as a folk hero.

And the public broadly dislikes the practice: Nearly three-quarters of respondents thought prior authorization was a “major” problem in , a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Indeed, Oz said during his June press conference that “violence in the streets” prompted the Trump administration to take on the issue of prior authorization reform in the private insurance industry.

Still, the administration is expanding the use of prior authorization in Medicare. CMS spokesperson Alexx Pons said both initiatives “serve the same goal of protecting patients and Medicare dollars.”

Unanswered Questions

The , WISeR — short for “Wasteful and Inappropriate Service Reduction” — will test the use of an AI algorithm in making prior authorization decisions for some Medicare services, including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy.

The federal government says such procedures are particularly vulnerable to “fraud, waste, and abuse” and could be held in check by prior authorization.

Other procedures may be added to the list. But services that are inpatient-only, emergency, or “would pose a substantial risk to patients if significantly delayed” would not be subject to the AI model’s assessment, according to the federal announcement.

While the use of AI in health insurance isn’t new, Medicare has been slow to adopt the private-sector tools. Medicare has historically used prior authorization in a limited way, with contractors who aren’t incentivized to deny services. But experts who have studied the plan believe the federal pilot could change that.

Pons told ºÚÁϳԹÏÍø News that no Medicare request will be denied before being reviewed by a “qualified human clinician,” and that vendors “are prohibited from compensation arrangements tied to denial rates.” While the government says vendors will be rewarded for savings, Pons said multiple safeguards will “remove any incentive to deny medically appropriate care.”

“Shared savings arrangements mean that vendors financially benefit when less care is delivered,” a structure that can create a powerful incentive for companies to deny medically necessary care, said Jennifer Brackeen, senior director of government affairs for the Washington State Hospital Association.

And doctors and policy experts say that’s only one concern.

Rathi said the plan “is not fully fleshed out” and relies on “messy and subjective” measures. The model, he said, ultimately depends on contractors to assess their own results, a choice that makes the results potentially suspect.

“I’m not sure they know, even, how they’re going to figure out whether this is helping or hurting patients,” he said.

Pons said the use of AI in the Medicare pilot will be “subject to strict oversight to ensure transparency, accountability, and alignment with Medicare rules and patient protection.”

“CMS remains committed to ensuring that automated tools support, not replace, clinically sound decision-making,” he said.

Experts agree that AI is theoretically capable of expediting what has been a cumbersome process marked by delays and denials that can harm patients’ health. Health insurers have argued that AI eliminates human error and bias and will save the health care system money. These companies have also insisted that humans, not computers, are ultimately reviewing coverage decisions.

But some scholars are doubtful that’s routinely happening.

“I think that there’s also probably a little bit of ambiguity over what constitutes ‘meaningful human review,’” said Amy Killelea, an assistant research professor at the Center on Health Insurance Reforms at Georgetown University.

A 2023 found that, over a two-month period, doctors at Cigna who reviewed requests for payment spent an average of only 1.2 seconds on each case.

Cigna spokesperson Justine Sessions told ºÚÁϳԹÏÍø News that the company does not use AI to deny care or claims. The ProPublica investigation referenced a “simple software-driven process that helped accelerate payments to clinicians for common, relatively low-cost tests and treatments, and it is not powered by AI,” Sessions said. “It was not used for prior authorizations.”

And yet class-action lawsuits filed against major health insurers have alleged that flawed AI models undermine doctor recommendations and fail to take patients’ unique needs into account, forcing some people to shoulder the financial burden of their care.

Meanwhile, a by the American Medical Association in February found that 61% think AI is “increasing prior authorization denials, exacerbating avoidable patient harms and escalating unnecessary waste now and into the future.”

Chris Bond, a spokesperson for the insurers’ trade group AHIP, told ºÚÁϳԹÏÍø News that the organization is “zeroed in” on implementing the commitments made to the government. Those include reducing the scope of prior authorization and making sure that communications with patients about denials and appeals are easy to understand.

‘This Is a Pilot’

The Medicare pilot program underscores ongoing concerns about prior authorization and raises new ones.

While private health insurers have been opaque about how they use AI and the extent to which they use prior authorization, policy researchers believe these algorithms are often programmed to automatically deny high-cost care.

“The more expensive it is, the more likely it is to be denied,” said Jennifer Oliva, a professor at the Maurer School of Law at Indiana University-Bloomington, whose work focuses on AI regulation and health coverage.

Oliva explained in a recent that when a patient is expected to die within a few years, health insurers are “motivated to rely on the algorithm.” As time passes and the patient or their provider is forced to appeal a denial, the chance of the patient dying during that process increases. The longer an appeal, the less likely the health insurer is to pay the claim, Oliva said.

“The No. 1 thing to do is make it very, very difficult for people to get high-cost services,” she said.

As the use of AI by health insurers is poised to grow, insurance company algorithms amount to a “regulatory blind spot” and demand more scrutiny, said Carmel Shachar, a faculty director at Harvard Law School’s Center for Health Law and Policy Innovation.

The WISeR pilot is “an interesting step” toward using AI to ensure that Medicare dollars are purchasing high-quality health care, she said. But the lack of details makes it difficult to determine whether it will work.

Politicians are grappling with some of the same questions.

“How is this being tested in the first place? How are you going to make sure that it is working and not denying care or producing higher rates of care denial?” asked DelBene, who to Oz with other Democrats demanding answers about the AI program. But Democrats aren’t the only ones worried.

Murphy, who co-chairs the House GOP Doctors Caucus, acknowledged that many physicians are concerned the WISeR pilot could overreach into their practice of medicine if the AI algorithm denies doctor-recommended care.

Meanwhile, House members of both parties recently supported a , a Florida Democrat, to block funding for the pilot in the fiscal 2026 budget of the Department of Health and Human Services.

AI in health care is here to stay, Murphy said, but it remains to be seen whether the WISeR pilot will save Medicare money or contribute to the problems already posed by prior authorization.

“This is a pilot, and I’m open to see what’s going to happen with this,” Murphy said, “but I will always, always err on the side that doctors know what’s best for their patients.”

This <a target="_blank" href="/aging/ai-medicare-prior-authorization-trump-pilot-program-wiser/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

It took years, a chain of conflicting decisions, and a health insurer switch before she finally won approval. She started treatment in January and now channels time and energy into helping other patients fight denials.

“One of the things I tell people when they come to me is: ‘Don’t panic. This isn’t a final no,’” said Nix, 55, of Statesville, North Carolina.

To control costs, nearly all health insurers use a system called prior authorization, which requires patients or their providers to seek approval before they can get certain procedures, tests, and prescriptions.

Denials can be appealed, but nearly half of insured adults who received a prior authorization denial in the past two years reported the appeals process was either somewhat or very difficult, according to , a health information nonprofit that includes ºÚÁϳԹÏÍø News.

“It’s overwhelming by design,” because insurers know confusion and fatigue cause people to give up, Nix said. “That’s exactly what they want you to do.”

The good news is you don’t have to be an insurance expert to get results, she said. “You just need to know how to push back.”

Here are tips to consider when faced with a prior authorization denial:

1. Know your insurance plan.

Do you have insurance through your job? A plan purchased through healthcare.gov? Medicare? Medicare Advantage? Medicaid?

These distinctions can be confusing, but they matter a great deal. Different categories of health insurance are governed by different agencies and are therefore subject to different prior authorization rules.

For example, federal marketplace plans, as well as Medicare and Medicare Advantage plans, are regulated by the U.S. Department of Health and Human Services. Employer-sponsored plans are regulated by the Department of Labor. Medicaid plans, administered by state agencies, are subject to both state and federal rules.

Learn the language specific to your policy. Health insurance companies do not apply prior authorization requirements uniformly across all plans. Read your policy closely to make sure your insurer is following its own rules, as well as regulations set by the state and federal government.

2. Work with your provider to appeal.

Kathleen Lavanchy, who retired in 2024 from a job at an inpatient rehabilitation hospital in the Philadelphia area, spent much of her career communicating with health insurance companies on behalf of patients.

Before you contact your health insurer, call your provider, Lavanchy said, and ask to speak to a medical care manager or someone in the office who handles prior authorization appeals.

The good news is that your doctor’s office may already be working on an appeal.

Medical staffers can act as “your voice,” Nix said. “They know all the language.”

You or your provider can request a “peer-to-peer” review during the appeals process, which allows your doctor to discuss your case over the phone with a medical professional who works for the insurance company.

3. Be organized.

Many hospitals and doctors use a system called MyChart to organize medical records, test results, and communications so that they are easily accessible. Similarly, patients should keep track of all materials related to an insurance appeal — records of phone calls, emails, snail mail, and in-app messages.

Everything should be organized, either digitally or on paper, so that it can be easily referenced, Nix said. At one point, she said, her own records proved that her insurance company had given conflicting information. The records were “the thing that saved me,” she said.

“Keep an amazing paper trail,” she said. “Every call, every letter, every name.”

Linda Jorgensen, executive director of the Special Needs Resource Project, a nonprofit offering online resources for patients with disabilities and their families, has advised patients who are fighting a denial to specifically keep paper copies of everything.

“If it isn’t on paper, it didn’t happen,” she said.

Jorgensen, who serves as a caregiver to an adult daughter with special needs, created you can print to help guide you when taking notes during phone calls with your insurance company. She advised asking the insurance representative for a “ticket number” and their name before proceeding with the conversation.

4. Appeal as soon as possible.

The silver lining is that most denials, if appealed, are overturned.

Medicare Advantage in January found that nearly 82% of prior authorization denials from 2019 through 2023 were partially or fully overturned upon appeal.

But the clock is ticking. Most health plans give you only six months to appeal the decision, according to in the Affordable Care Act.

“Don’t dillydally,” Jorgensen advised, especially if you’re sending a paper appeal, or any supporting documents, through the U.S. Postal Service. She recommends filing quickly, and at least four weeks before the deadline.

For the sake of speed, some people are for help crafting customizable appeal letters.

5. Ask your HR department for help.

If you get your health insurance through an employer, there’s a good chance your health plan is “self-funded” or “self-insured.” That means your employer contracts with a health insurance company to administer benefits, but your employer shoulders the cost of your care.

Why does that matter? Under self-funded plans, decisions about what is or isn’t covered ultimately rest with your employer.

Let’s say, for example, your doctor has recommended that you undergo surgery, and your insurer has denied prior authorization for it, deeming the procedure “not medically necessary,” a phrase commonly used. If your plan is self-funded, you can appeal to the human resources department at your job, because your employer is on the hook for your health care costs — not the insurer.

Of course, there’s no guarantee your employer will agree to pay. But, at the very least, it’s worth reaching out for help.

6. Find an advocate.

Many states operate free , available by phone or email, which can help you file an appeal. They can explain your benefits and may intervene if your insurance company isn’t complying with requirements.

Beyond that, some nonprofit advocacy groups, such as the Patient Advocate Foundation, might help. On the foundation’s website is . For those battling severe disease, foundation staffers can work with you one-on-one to fight a denial.

7. Make noise.

We’ve written about this before. Sometimes, when patients and doctors shame insurers online, denials get overturned.

The same holds when patients contact lawmakers. State laws regulate some categories of health insurance, and when it comes to setting policy, state lawmakers have the power to hold insurance companies accountable.

Reaching out to your legislator isn’t guaranteed to work, but it might be worth a shot.

Finally, if you’re interested in sharing your experiences with a journalist, . We’d like to hear from you.

This <a target="_blank" href="/health-care-costs/health-insurance-denial-prior-authorization-7-tips-to-file-appeal/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Dozens of insurance companies, including Cigna, Aetna, Humana, and UnitedHealthcare, agreed to several measures, which include making fewer medical procedures subject to prior authorization and speeding up the review process. Insurers also pledged to use clear language when communicating with patients and promised that medical professionals would review coverage denials.

While Trump administration officials applauded the insurance industry for its willingness to change, they acknowledged limitations of the agreement.

“The pledge is not a mandate,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said during a news conference. “This is an opportunity for the industry to show itself.”

Oz said that insurance preapprovals for some procedures are appropriate, citing knee arthroscopy, a common, minimally invasive procedure to diagnose and treat knee problems that some studies suggest . Chris Klomp, director of the Center for Medicare at CMS, recommended prior authorization be eliminated for vaginal deliveries, colonoscopies, and cataract surgeries, among other procedures. Health insurers said the changes would benefit most Americans, including those with commercial or private coverage, Medicare Advantage, and Medicaid managed care.

The insurers have also agreed that patients who switch insurance plans may continue receiving treatment or other health care services for 90 days without facing immediate prior authorization requirements imposed by their new insurer.

But health policy analysts say prior authorization — a system that forces some people to delay care or abandon treatment — may continue to pose serious health consequences for affected patients. That said, many people may not notice a difference, even if insurers follow through on their new commitments.

“So much of the prior authorization process is behind the black box,” said Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Often, she said, patients aren’t even aware that they’re subject to prior authorization requirements until they face a denial.

“I’m not sure how this changes that,” Pestaina said.

The follows the killing of UnitedHealthcare CEO Brian Thompson, who was shot in midtown Manhattan in early December on the way to an investor meeting, forcing the issue of prior authorization to the forefront.

Oz acknowledged “violence in the streets” prompted Monday’s announcement. Klomp told ºÚÁϳԹÏÍø News that insurers were reacting to the shooting because the problem has “reached a fever pitch.” Health insurance CEOs now move with security details wherever they go, Klomp said.

“There’s no question that health insurers have a reputation problem,” said Robert Hartwig, an insurance expert and a clinical associate professor at the University of South Carolina.

The pledge shows that insurers are hoping to stave off “more draconian” legislation or regulation in the future, Hartwig said.

But government interventions to improve prior authorization will be used “if we’re forced to use them,” Oz said during the news conference.

“The administration has made it clear we’re not going to tolerate it anymore,” he said. “So either you fix it or we’re going to fix it.”

Here are the key takeaways for consumers:

1. Prior authorization isn’t going anywhere.

Health insurers will still be allowed to deny doctor-recommended care, which is arguably the biggest criticism that patients and providers level against insurance companies. And it isn’t clear how the new commitments will protect the sickest patients, such as those diagnosed with cancer, who need the most expensive treatment.

2. Reform efforts aren’t new.

Most states have already passed at least one law imposing requirements on insurers, often intended to reduce the time patients spend waiting for answers from their insurance company and to require transparency from insurers about which prescriptions and procedures require preapproval. Some states have also enacted “gold card” programs for doctors that allow physicians with a robust record of prior authorization approvals to bypass the requirements.

Nationally, rules proposed by the first Trump administration and finalized by the Biden administration are already set to take effect next year. They will require insurers to respond to requests within seven days or 72 hours, depending on their urgency, and to process prior authorization requests electronically, instead of by phone or fax, among other changes. Those rules apply only to certain categories of insurance, including Medicare Advantage and Medicaid.

Beyond that, some insurance companies committed to improvement long before Monday’s announcement. Earlier this year, UnitedHealthcare pledged to reduce prior authorization volume by 10%. Cigna announced its own set of improvements in February.

3. Insurance companies are already supposed to be doing some of these things.

For example, the Affordable Care Act already requires insurers to communicate with patients in plain language about health plan benefits and coverage.

But denial letters remain confusing because companies tend to use jargon. For instance, AHIP, the health insurance industry trade group, used the term “non-approved requests” in Monday’s announcement.

Insurers also pledged that medical professionals would continue to review prior authorization denials. AHIP claims this is “a standard already in place.” But recent lawsuits allege otherwise, accusing companies of denying claims in a matter of seconds.

4. Health insurers will increasingly rely on artificial intelligence.

Health insurers issue millions of denials every year, though most prior authorization requests are quickly, sometimes even instantly, approved.

The use of AI in making prior authorization decisions isn’t new — and it will probably continue to ramp up, with insurers pledging Monday to issue 80% of prior authorization decisions “in real-time” by 2027.

“Artificial intelligence should help this tremendously,” Rep. Gregory Murphy (R-N.C.), a physician, said during the news conference.

“But remember, artificial intelligence is only as good as what you put into it,” he added.

Results from a survey published by the American Medical Association in February indicated 61% of physicians are concerned that the use of AI by insurance companies is already increasing denials.

5. Key details remain up in the air.

Oz said CMS will post a full list of participating insurers this summer, while other details will become public by January.

He said insurers have agreed to post data about their use of prior authorization on a public dashboard, but it isn’t clear when that platform will be unveiled. The same holds true for “performance targets” that Oz spoke of during the news conference. He did not name specific targets, indicate how they will be made public, or specify how the government would enforce them.

While the AMA, which represents doctors, applauded the announcement, “patients and physicians will need specifics demonstrating that the latest insurer pledge will yield substantive actions,” the association’s president, Bobby Mukkamala, said in a statement. He noted that health insurers made “past promises” to improve prior authorization in 2018.

Meanwhile, it also remains unclear what services insurers will ultimately agree to release from prior authorization requirements.

Patient advocates are in the process of identifying “low-value codes,” Oz said, that should not require preapproval, but it is unknown when those codes will be made public or when insurers will agree to release them from prior authorization rules.

Do you have an experience with prior authorization you’d like to share? to tell your story.

This <a target="_blank" href="/health-industry/5-takeaways-from-insurers-pledge-to-improve-prior-authorization/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Two years later, grueling rounds of chemotherapy have slowed the cancer’s progress, even as it has continued to spread. But chemotherapy has also ravaged Tennant’s body and his quality of life.

Recently, however, the 58-year-old had reason to hope things would improve. Last fall, his wife, Rebecca, learned of a relatively new, noninvasive procedure called histotripsy, which uses targeted ultrasound waves to destroy tumors in the liver. The treatment could extend his life and buy him more downtime between rounds of chemotherapy.

Early this year, Tennant’s oncologist agreed he was a good candidate since the largest tumor in his body is in his liver. But that’s when his family began fighting another adversary: their health insurer, which decided the treatment was “not medically necessary,” according to insurance paperwork.

Health insurers issue millions of denials every year. And like the Tennants, many patients find themselves stuck in a convoluted appeals process marked by long wait times, frustrating customer service encounters, and decisions by medical professionals they’ve never met who may lack relevant training.

Recent federal and state efforts, as well as changes undertaken by insurance companies themselves, have attempted to improve a 50-year-old system that disproportionately burdens some of the sickest patients at the worst times. And yet many doctors complain that insurance denials are worse than ever as the use of prior authorization has ramped up in recent years, reporting by ºÚÁϳԹÏÍø News and NBC News found.

When the Tennant family was told histotripsy would cost $50,000 and insurance wouldn’t cover it, they appealed the denial four times.

“It’s a big mess,” said Rebecca Tennant, who described feeling like a pingpong ball, bouncing between the insurer and various health care companies involved in the appeals process.

“There’s literally nothing we can do to get them to change,” she said in an April interview with ºÚÁϳԹÏÍø News. “They’re, like, not accountable to anyone.”

While the killing of UnitedHealthcare chief executive Brian Thompson in December incited a fresh wave of public fury about denials, there is almost no hope of meaningful change on the horizon, said Jay Pickern, an assistant professor of health services administration at Auburn University.

“You would think the murder of a major health insurance CEO on the streets of New York in broad daylight would be a major watershed moment,” Pickern said. Yet, once the news cycle died down, “everything went back to the status quo.”

An Unintended Consequence of Health Reform?

Prior authorization varies by plan but often requires patients or their providers to get permission (also called precertification, preauthorization, or preapproval) before filling prescriptions, scheduling imaging, surgery, or an inpatient hospital stay, among other expenses.

The practice isn’t new. Insurers have used prior authorization for decades to limit fraud, prevent patient harm, and control costs. In some cases, it is used to intentionally generate profits for health insurers, according to a . By denying costly care, companies pay less for health care expenses while still collecting premiums.

“At the end of the day, they’re a business and they exist to make money,” said Pickern, who on patient care for The American Journal of Managed Care.

For most patients, though, the process works seamlessly. Prior authorization mostly happens behind the scenes, almost always electronically, and nearly all requests are quickly, or even instantly, approved.

But the use of prior authorization has also increased in recent years. That’s partly due to the growth of enrollment in Medicare Advantage plans, which compared with original Medicare. Some health policy experts also point to the passage of the Affordable Care Act in 2010, which prohibited health insurers from denying coverage to patients with preexisting conditions, prompting companies to find other ways to control costs.

“But we can’t really prove this,” said Kaye Pestaina, director of the Program on Patient and Consumer Protection at KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News. Health insurers haven’t been historically transparent about which services require prior authorization, she said, making it difficult to draw comparisons before and after the passage of the Affordable Care Act.

Meanwhile, many states are looking to overhaul the prior authorization process.

In March, that will require health insurers to publicly post a list of health care services and codes for which prior authorization is required. A North Carolina bill would require doctors who review patient appeals to have practiced medicine in the same specialty as the patient’s provider. The West Virginia Legislature passed bills in both 2019 and 2023 requiring insurers to respond to nonurgent authorization requests within five days and more urgent requests within two days, among other mandates.

And in 2014, the South Carolina Department of Health and Human Services temporarily lifted all prior authorization requirements for Medicaid beneficiaries seeking rehabilitative behavioral health services.

Federal rules to modify prior authorization that were introduced by the first Trump administration and finalized by the Biden administration are set to take effect next year, with the aim of streamlining the process, reducing wait times, and improving transparency.

These changes were supported by AHIP, a trade group that represents health insurers.

‘Sick With Little Recourse’

But the new federal rules won’t prevent insurance companies from denying payment for doctor-recommended treatment, and they apply only to some categories of health insurance, including Medicare Advantage and Medicaid. Nearly half the U.S. population is covered by employer-sponsored plans, which remain untouched by the new rules.

For some patients, the stakes couldn’t be higher.

On May 12, Alexander Schrift, 35, died at home in San Antonio, Florida, less than two months after his insurance company refused to cover the cancer drug ribociclib. It’s used to treat breast cancer but in treating the same type of brain tumor Schrift was diagnosed with in 2022, according to researchers at the Dana-Farber Cancer Institute in Boston and the Institute of Cancer Research in London.

But Schrift’s insurance company refused to pay. The Right to Try Act, signed by President Donald Trump in 2018, entitles patients with terminal illnesses to try experimental drugs, but it does not obligate insurance companies to pay for them.

In May, Sheldon Ekirch, 30, of Henrico, Virginia, said her parents withdrew money from their retirement savings to pay for treatment denied by her health insurance company.

Ekirch, who was diagnosed with small fiber neuropathy in 2023, was recommended by her doctor to try an expensive blood plasma treatment called intravenous immunoglobulin to ease her near-constant pain. In April, a state agency charged with reviewing insurance denials upheld her insurer’s decision. Out-of-pocket, the treatment may cost her parents tens of thousands of dollars.

“Never in a million years did I think I’d end up here,” Ekirch said, “sick with little recourse.”

Earlier this year, New Jersey congressman Jefferson Van Drew, a Republican, that would eliminate prior authorization altogether. But history suggests that would create new problems.

When South Carolina Medicaid lifted prior authorization for rehabilitative behavioral health services in 2014, the department’s costs for those services skyrocketed from $300,000 to $2 million per week, creating a $54 million budget shortfall after new providers flooded the market. Some providers were eventually referred to the South Carolina Attorney General’s Office for Medicaid fraud investigation. The state Medicaid agency eventually reinstated prior authorization for specific services, spokesperson Jeff Leieritz said.

What happened in South Carolina illustrates a common argument made by insurers: Prior authorization prevents fraud, reduces overspending, and guards against potential harm to patients.

On the other hand, many doctors and patients claim that cost-containment strategies, including prior authorization, do more harm than good.

On Feb. 3, 2024, Jeff Hall of Estero, Florida, became paralyzed from the neck down and spent weeks in a coma after he suddenly developed Guillain-Barré Syndrome. The cause of his illness remains unknown.

Hall, now 51, argued that the Florida Blue health insurance plan he purchased on the federal marketplace hindered his recovery by capping the number of days he was allowed to remain in an acute rehabilitation hospital last year.

Hall said that after he was forced to “step down” to a lower-level nursing facility, his health deteriorated so rapidly within six days that he was sent to the emergency room, placed on a ventilator, and required a second tracheostomy. Hall believes the insurance company’s coverage limits set his recovery back by months — and, ironically, cost the insurer more. His wife, Julie, estimated Jeff’s medical bills have exceeded $5 million, and most of his care has been covered by his insurer.

“Getting better is not always the goal of an insurance company. It’s a business,” Jeff Hall said. “They don’t care.”

In a prepared statement, Florida Blue spokesperson Jose Cano said the company understands “it can be a challenge when a member reaches the limit of their coverage for a specific service or treatment.” He encouraged members affected by coverage limits to contact their health care providers to “explore service and treatment options.”

A ‘Rare and Exceptional’ Reversal

Back in West Virginia, Eric and Rebecca Tennant say they are realistic about Eric’s prognosis.

They never expected histotripsy to cure his cancer. At best, the procedure could buy him more time and might allow him to take an extended break from chemotherapy. That makes it worth trying, they said.

As a safety instructor with the West Virginia Office of Miners’ Health Safety and Training, Eric Tennant is a state employee and is insured by West Virginia’s Public Employees Insurance Agency.

As the Tennants pleaded with the state insurance agency to cover histotripsy, they faced a list of other companies involved in the decision, including UMR, a UnitedHealthcare subsidiary that contracts with West Virginia to manage the public employee plans, and MES Peer Review Services, a Massachusetts company that upheld the insurer’s decision in March, citing that histotripsy is “unproven in this case and is not medically necessary.”

None of their appeals worked. After ºÚÁϳԹÏÍø News and NBC News reached out to West Virginia’s Public Employees Insurance Agency with questions for this article, the agency changed its mind, explaining the insurer had consulted with medical experts to further evaluate the case.

“This decision reflects a rare and exceptional situation” and does not represent a change in the Public Employees Insurance Agency’s overall coverage policies,” Director Brent Wolfingbarger said in a prepared statement to ºÚÁϳԹÏÍø News.

In a separate prepared statement, UnitedHealthcare spokesperson Eric Hausman said the company sympathizes with “anyone navigating through life-threatening care decisions.”

“Currently, there is no evidence that histotripsy is as effective as alternative treatment options available,” he said in late May, after the earlier insurance denials were reversed, “and its impact on survival or cancer recurrence is unknown.”

MES Peer Review Services did not respond to a request for an interview.

Meanwhile, Rebecca Tennant worries it might be too late. She said her husband was first evaluated for histotripsy in February. But his health has recently taken a turn for the worse. In late May and early June, she said, he spent five days in the hospital after developing heart and lung complications.

Eric Tennant is no longer considered a viable candidate for histotripsy, his wife said, although the Tennants are hopeful that will change if his health improves. Scans scheduled for July will determine whether his cancer has continued to progress. Rebecca Tennant blames her husband’s insurance plan for wasting months of their time.

“Time is precious,” she said. “They know he has stage 4 cancer, and it’s almost like they don’t care if he lives or dies.”

Do you have an experience with prior authorization you’d like to share?  to tell your story.

NBC News health and medical unit producer Jason Kane and correspondent Erin McLaughlin contributed to this report.

This <a target="_blank" href="/health-care-costs/prior-authorization-insurer-denials-patients-run-out-of-options/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">