If you have ever had to delay a procedure because you’re waiting for a prior authorization, you probably have a good understanding of this blog post. In health insurance parlance, a prior authorization, or pre-authorization, is a process used by insurance companies to determine if doing a planned procedure is justified and worthy of payment. The doctor ordering the procedure initiates the approval process and must answer questions from the insurer that determine if the procedure meets criteria for coverage. If the criteria are met, the procedure is approved and can be done. The insurance company agrees, also, to cover the cost of the procedure.
Sometimes the case is straightforward and approval is given quickly, but sometimes it takes weeks, delaying the procedure. If approval is denied, the procedure is further delayed until an appeal can be filed and approved.
On May 21st, an article on medscape.com reported on the inconsistencies physicians deal with in obtaining prior authorization. What occurred is that major health insurers have very inconsistent rules for authorization meaning that Aetna, Humana, United Health Care, and Anthem of California each use different criteria for approving the same procedure. Researchers from Stanford, Georgetown, and United Health Group “found…substantial variation in both the criteria and requirements for prior authorization….leading to administrative burdens and treatment delays.” The American Medical Association, the AMA, surveyed physicians and found that “95% of them said prior authorizations delay necessary care.” Plus they find them more of an annoyance than an asset.
It all stems from the physician office’s use of electronic medical records to apply for prior authorization. Because of the the variations in insurer approval criteria, the protocols used by a physician’s health record, won’t work for all insurers.
The solution lies in “requiring insurers to adopt a standardized digital framework for all prior authorization rules.” Then before he leaves the doctor’s office, the patient would know if the procedure was approved and could schedule it, avoiding delay. This also relates to the “interoperability” of electronic medical record systems, and the ability to successfully communicate with and interact with the EMR of other physicians, hospitals, or organizations. If all health care entities used the same digital system, accessing records between offices and hospitals would be timely and much easier. Then, the ER could access Mr. Smith’s records from Dr. G’s office and Dr. G could access the record when Mr. Smith goes to the ER. Interoperability already exists, but “is still evolving.” It’s a huge challenge to get every patient and health care entity on the same “foundational and structural exchange,” but that is the ultimate goal.
The interoperability debate has been going on for years and progress is being made. When it is completed, however, continuity and coordination of care will improve greatly.
Reference: Weber S. Prior Authorization Rules Show Little Consistency Across Major Insurers, Study Finds. medscape.com 2026 May 21.
