Your Doctor Says Yes and a Spreadsheet Says Prove It

There was a charming period in human history when getting sick involved finding a doctor.

America improved this primitive arrangement by adding a third party whose medical contribution is asking whether you’ve considered remaining sick.

Welcome to prior authorization, the health insurance ritual where your physician examines you, diagnoses you, recommends treatment, and then somebody at an insurance company gets to lean back metaphorically and say, “I don’t know, Doctor. Sell me on the MRI.”

Nothing screams advanced civilization like making a neurologist explain neurological medicine to an organization whose principal clinical instrument is a deductible.

In fairness, prior authorization has a legitimate purpose. Even CMS acknowledges that it can help ensure care is medically necessary and appropriate. Health care is expensive. Doctors aren’t infallible. Waste exists. Unnecessary procedures happen. Somebody should question whether every ache requires a $9,000 scan and a ceremonial procession through orthopedics.

Fine.

We’ve apparently decided the solution is to make necessary medicine audition for a role in its own treatment plan.

According to the American Medical Association’s 2025 survey of 1,000 practicing physicians, published in 2026, 95% said prior authorization delays necessary care. Seventy-nine percent said patients sometimes abandon treatment because of authorization problems. Twenty-six percent reported that prior authorization had contributed to a serious adverse event involving a patient, including hospitalization, permanent impairment or death. Physicians reported completing an average of 40 prior authorizations every week, consuming about 13 hours of physician and staff time.

Thirteen hours.

We trained physicians for a decade so they could spend a day and a half each week proving to an insurer that they continue to believe the thing they already wrote down.

That is an astonishing use of medical expertise.

“Mrs. Patterson, your biopsy suggests cancer, so naturally I’d like to discuss treatment. Unfortunately, I have to go explain oncology to a website that forgot my password.”

The AMA survey gets even funnier, assuming your sense of humor was raised by wolves. Only about one-third of the surveyed physicians expressed trust that recent insurer promises would meaningfully reform prior authorization, and only 16% of doctors participating in peer-to-peer reviews said the insurer’s representative was consistently qualified to evaluate the relevant clinical issues.

Peer-to-peer.

Apparently “peer” has undergone the same linguistic evolution as “customer service.”

Your cardiologist may get to discuss your heart with somebody whose relationship to cardiology is that both of them have seen one.

Then there are the denials.

KFF analyzed newly required 2025 data from large insurers and found that they denied about 12% of standard prior authorization requests in Medicare Advantage, 14% in Medicaid managed care, and 18% in Affordable Care Act Marketplace plans. The rates varied considerably among insurers, and some denials were overturned after appeal.

Which raises a fascinating question.

If a denial is eventually reversed, what exactly happened during the interval?

Did medical reality change?

Did the patient’s vertebrae submit additional documentation?

Did the tumor acquire a reference number?

Or did enough humans push enough buttons until the computer finally stopped saying no?

We have somehow built a health care system where “medically necessary” can mean “medically necessary after the fourth phone call.”

Government regulators clearly know the process has become ridiculous. Beginning in 2026, CMS requires covered payers to make expedited prior authorization decisions within 72 hours and standard decisions within seven calendar days, subject to the rule’s specified scope and exceptions. Covered payers must also give specific reasons for denials. Electronic prior authorization interfaces arrive in 2027.

Read that again.

We reached a point where federal regulators had to formally require insurance companies to explain why they said no.

For years, apparently, “because go screw yourself” simply lacked standardized coding.

The deeper absurdity is that every attempt to control health care spending creates another administrative organism feeding on health care spending. Insurers hire people to scrutinize doctors. Hospitals hire people to answer insurers. Practices employ staff whose job is navigating authorization. Consultants explain the rules. Software companies sell systems to manage the process. Regulators regulate the regulators of the treatment.

Eventually there’s one patient, one physician and 11 people discussing whether the first two should be allowed to proceed.

This can be fixed without pretending every requested treatment deserves automatic approval.

Start with services that insurers overwhelmingly approve. Stop demanding prior authorization for them. If a physician repeatedly receives approval for the same treatment, give that physician a gold-card exemption. Versions of this approach already exist, and medical groups have advocated expanding it.

Require genuine peer review. If an oncologist’s treatment is being challenged on clinical grounds, the reviewer should understand oncology. “Has access to Google” is an inadequate medical subspecialty.

Make authorization electronic and standardized across insurers. Publish denial rates, appeal rates and reversal rates in language patients can understand. If an insurer routinely denies requests that it later approves, regulators should ask why its first answer deserves anybody’s time.

And put teeth into deadlines. When an insurer fails to decide within the required period, approval should become the default. Amazing how quickly bureaucracy discovers urgency when procrastination starts costing the bureaucracy.

Prior authorization should be a scalpel used against genuinely questionable or unusually expensive care.

We’ve turned it into airport security for medicine.

Everybody takes off their shoes. Everybody empties their pockets. Everybody waits. Ninety-nine people eventually proceed exactly where they were going, and the institution congratulates itself because somebody confiscated a bottle of shampoo.

Americans already accept that insurers help determine what they’ll pay for.

Apparently we also accepted something far stranger.

The doctor gets to decide what you need.

Then the people paying the doctor get to decide whether the doctor meant it.

And somewhere, an insurance portal would like your date of birth again.

References

For anyone wondering whether American health care truly achieved this level of self-parody, several large institutions have thoughtfully documented the punchline themselves.

American Medical Association, AMA Survey Prior Authorization Reform Pledge Falls Short With Physicians
https://www.ama-assn.org/press-center/ama-press-releases/ama-survey-prior-authorization-reform-pledge-falls-short-physicians

American Medical Association, Latest Prior Auth Survey Shows Promised Reform Remains Elusive
https://www.ama-assn.org/about/leadership/latest-prior-auth-survey-shows-promised-reform-remains-elusive

Centers for Medicare & Medicaid Services, CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process
https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-improve-prior-authorization-process

Centers for Medicare & Medicaid Services, CMS Interoperability and Prior Authorization Final Rule CMS-0057-F
https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f

Centers for Medicare & Medicaid Services, Moving Prior Authorization into the 21st Century
https://www.cms.gov/newsroom/blog/moving-prior-authorization-21st-century

KFF, Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain
https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/

American Medical Association, Fixing Prior Auth Nearly 40 Prior Authorizations a Week Is Way Too Many
https://www.ama-assn.org/practice-management/prior-authorization/fixing-prior-auth-nearly-40-prior-authorizations-week-way

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Tammy Pondsmith writes satire, distrusts insurance portals, and considers pending review America’s most profitable diagnosis.

As the Voice of the Veteran Community, The Havok Journal seeks to publish a variety of perspectives on a number of sensitive subjects. Unless specifically noted otherwise, nothing we publish is an official point of view of The Havok Journal or any part of the U.S. government.