When Paula Chestnut needed hip replacement surgery last year, a pre-operative X-ray found irregularities in her chest.<\/p>\n

As a smoker for 40 years, Chestnut was at high risk for lung cancer. A specialist in Los Angeles recommended the 67-year-old undergo an MRI, a high-resolution image that could help spot the disease.<\/p>\n

But her MRI appointment kept getting canceled, Chestnut\u2019s son, Jaron Roux, told KHN. First, it was scheduled at the wrong hospital. Next, the provider wasn\u2019t available. The ultimate roadblock she faced, Roux said, arrived when Chestnut\u2019s health insurer deemed the MRI medically unnecessary and would not authorize the visit.<\/p>\n

\u201cOn at least four or five occasions, she called me up, hysterical,\u201d Roux said.<\/p>\n

Months later, Chestnut, struggling to breathe, was rushed to the emergency room. A tumor in her chest had become so large that it was pressing against her windpipe. Doctors started a regimen of chemotherapy, but it was too late. Despite treatment, she died in the hospital within six weeks of being admitted.<\/p>\n

Though Roux doesn\u2019t fully blame the health insurer for his mother\u2019s death, \u201cit was a contributing factor,\u201d he said. \u201cIt limited her options.\u201d<\/p>\n

Few things about the American health care system infuriate patients and doctors more than prior authorization, a common tool whose use by insurers has exploded in recent years.<\/p>\n

Prior authorization, or pre-certification, was designed decades ago to prevent doctors from ordering expensive tests or procedures that are not indicated or needed, with the aim of delivering cost-effective care.<\/p>\n

Originally focused on the costliest types of care, such as cancer treatment, insurers now commonly require prior authorization for many mundane medical encounters, including basic imaging and prescription refills. In a 2021 survey<\/a> conducted by the American Medical Association, 40% of physicians said they have staffers who work exclusively on prior authorization.<\/p>\n

So today, instead of providing a guardrail against useless, expensive treatment, pre-authorization prevents patients from getting the vital care they need, researchers and doctors say.<\/p>\n

\u201cThe prior authorization system should be completely done away with in physicians\u2019 offices,\u201d said Dr. Shikha Jain<\/a>, a Chicago hematologist-oncologist. \u201cIt\u2019s really devastating, these unnecessary delays.\u201d<\/p>\n

In December, the federal government proposed several changes<\/a> that would force health plans, including Medicaid, Medicare Advantage, and federal Affordable Care Act marketplace plans, to speed up prior authorization decisions and provide more information about the reasons for denials. Starting in 2026, it would require plans to respond to a standard prior authorization request within seven days, typically, instead of the current 14, and within 72 hours for urgent requests. The proposed rule was scheduled to be open for public comment<\/a> through March 13.<\/p>\n

Although groups like AHIP, an industry trade group formerly called America\u2019s Health Insurance Plans, and the American Medical Association, which represents more than 250,000 physicians in the United States, have expressed support for the proposed changes, some doctors feel they don\u2019t go far enough.<\/p>\n

\u201cSeven days is still way too long,\u201d said Dr. Julie Kanter<\/a>, a hematologist in Birmingham, Alabama, whose sickle cell patients can\u2019t delay care when they arrive at the hospital showing signs of stroke. \u201cWe need to move very quickly. We have to make decisions.\u201d<\/p>\n

Meanwhile, some states have passed their own laws governing the process. In Oregon, for example, health insurers must respond to nonemergency prior authorization requests within two business days<\/a>. In Michigan, insurers must report annual prior authorization data<\/a>, including the number of requests denied and appeals received. Other states have adopted or are considering similar legislation<\/a>, while in many places insurers regularly take four to six weeks for non-urgent appeals.<\/p>\n

Waiting for health insurers to authorize care comes with consequences for patients, various studies show. It has led to delays in cancer care<\/a> in Pennsylvania, meant sick children in Colorado<\/a> were more likely to be hospitalized, and blocked low-income patients across the country<\/a> from getting treatment for opioid addiction.<\/p>\n

In some cases, care has been denied and never obtained. In others, prior authorization proved a potent but indirect deterrent, as few patients have the fortitude, time, or resources to navigate what can be a labyrinthine process of denials and appeals. They simply gave up, because fighting denials often requires patients to spend hours on the phone and computer to submit multiple forms.<\/p>\n

Erin Conlisk, a social science researcher for the University of California-Riverside, estimated she spent dozens of hours last summer trying to obtain prior authorization for a 6-mile round-trip ambulance ride to get her mother to a clinic in San Diego.<\/p>\n

Her 81-year-old mother has rheumatoid arthritis and has had trouble sitting up, walking, or standing without help after she damaged a tendon in her pelvis last year.<\/p>\n

Conlisk thought her mom\u2019s case was clear-cut, especially since they had successfully scheduled an ambulance transport a few weeks earlier to the same clinic. But the ambulance didn\u2019t show on the day Conlisk was told it would. No one notified them the ride hadn\u2019t been pre-authorized.<\/p>\n