A federal rule now requires payers to decide prior authorization requests within 72 hours or seven days, explain denials, and publish their numbers. These are real improvements. But the evidence suggests much of prior authorization delays care it goes on to approve: in one study, 58 of 61 denied imaging requests (95.1%) were approved once reviewed. The rule speeds the process without changing its standard, and it excludes drugs.
A federal rule now requires health plans to decide expedited prior authorization requests within 72 hours and standard requests within seven calendar days, to give a specific reason for every denial, and to publish their prior authorization numbers each year. The CMS Interoperability and Prior Authorization final rule (CMS-0057-F) will make prior authorization faster, more predictable, and more visible.
It will not make prior authorization more accurate, and the evidence suggests accuracy is the actual problem. In one study, 58 of 61 imaging requests that had been denied (95.1%) were approved once a reviewer looked at them.
An earlier brief on utilization management argued that reviewing whether care is necessary has a legitimate purpose, and that its reputation for obstruction is not entirely unearned. Prior authorization is where that tension is sharpest.
Denials are usually overturned
The most uncomfortable pattern in the evidence is how often a denial reverses once someone examines it.
In a prospective study at an orthopedic practice, 58 of 61 denied advanced-imaging requests (95.1%) were approved after peer-to-peer review. The median time from the office visit to that review was nine days. Among the approved studies patients completed, 74.5% confirmed the diagnosis the physician had suspected. The authors’ conclusion: care was delayed.
The same shape appears elsewhere. In a national sample of children with inflammatory bowel disease facing payer barriers to biologic therapy, 77% of initial denials were ultimately approved. The median time to receiving the medication was 18 days. Sixty percent of those children experienced adverse outcomes or worse quality of life from the delay, and 21% were hospitalized.
A review process that reverses itself most of the time is not mainly a filter. It is a queue.
The process rarely changes the treatment
Surveyed orthopedic surgeons describe the same thing from the other side. A majority (57%) said prior authorization rarely or never changed the treatment they ultimately provided, and 56% said it rarely or never followed evidence-based guidelines. Meanwhile 71% of practices employ at least one staff member whose only job is prior authorization, and the average practice spends 15 hours a week on it.
That is a process that consumes real resources, delays care by days or weeks, and then mostly permits the care it delayed.
Two cautions belong here. First, these are small, specialty-specific studies, and the surgeon survey had a 13% response rate, which selects for the aggrieved. They are suggestive, not national estimates. Second, a high reversal rate is not by itself proof the denials were wrong: if physicians appeal only their strongest cases, a 95% reversal rate partly reflects that selection rather than payer error. Even discounted for both, the direction is hard to dismiss.
What the rule fixes, and what it misses
CMS-0057-F attacks the delay. It does not touch the standard.
A payer that denies a request it would have approved on review will now deny it within seven days instead of thirty, explain why, and report the totals. The patient still waits, appeals, and eventually gets the care. The practice still staffs the appeal. Automating a process whose denials do not survive scrutiny mostly automates the delay.
The rule also carves out drugs. It states plainly that it “does not apply to prior authorization decisions for drugs.” The pediatric cases above were biologics, so the clearest documented harm in this evidence, children hospitalized waiting for medication their payers went on to approve, falls entirely outside the rule’s reach. Its coverage is also limited to Medicare Advantage, Medicaid and CHIP, and qualified health plans on the federal exchanges. Commercial employer coverage is untouched.
Why it matters more under value-based care
In fee-for-service, prior authorization is a brake the payer applies against a provider whose incentive is to do more. Under a value-based arrangement, the provider already bears the cost of unnecessary care. The brake is being applied to someone who is already braking.
There the administrative burden is not a cost of restraint. It is deadweight: two organizations paying staff to argue about a decision they both now have a financial reason to get right. Every hour of that 15-hour week is an hour not spent on care management.
So the reform worth pursuing is not a faster prior authorization process but a smaller one. Where a provider bears meaningful two-sided risk, the case for reviewing each decision largely dissolves, which is the logic behind gold-carding, exempting reliably appropriate ordering patterns from review. CMS-0057-F is a floor for the plumbing, not an answer to what should be reviewed at all.
What to watch
The rule’s most useful provision may be the public reporting. Starting in 2026, payers must publish their prior authorization metrics. For the first time, approval rates, denial rates, and appeal outcomes will be visible at scale rather than inferred from small single-specialty studies. The evidence base here is thin precisely because that data has never existed.
If those numbers show what the small studies suggest, the argument shifts from anecdote to arithmetic, and the case for shrinking prior authorization inside risk-bearing arrangements gets much harder to wave away.
Sources
- CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). Fact sheet. Centers for Medicare & Medicaid Services; January 17, 2024. cms.gov (opens in a new tab)
- Imam N, Zaifman JM, Bassora R, et al. Nearly All Peer-to-Peer Reviews for CT and MRI Prior Authorization Denials for Orthopedic Specialists Are Approved. Orthopedics. 2024;47(3):141-146. doi:10.3928/01477447-20231027-08 (opens in a new tab)
- Constant BD, Adler J, Gold BD, et al. National perspectives of barriers by insurance and pharmacy benefit managers in pediatric inflammatory bowel disease. JPGN Reports. 2025;6(2):80-90. doi:10.1002/jpr3.70004 (opens in a new tab)
- Pereira DE, Kamara E, Krueger CA, et al. Prior Authorization in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership. The Journal of Arthroplasty. 2023;38(7):1203-1208.e3. doi:10.1016/j.arth.2023.01.022 (opens in a new tab)