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Prior authorization: what physicians say, in their own words

Last updated September 20, 2026.

The short answer

Read together, the 90 essays and podcast transcripts on this page make one argument that has not changed in eighteen years and one that has. The constant is that prior authorization costs physicians hours they are not paid for and delays care for patients who are. What changed is the frame: the early posts treated it as a paperwork nuisance, the middle years as an insurer tactic, and the essays since 2025 as a burnout driver now being handed to algorithms. Posts mentioning AI went from 19 percent in 2020 to 2024 to 65 percent in 2025 and 2026. The record also contains the dissent: physicians who argue the concept is defensible and the execution is the problem, and one who reviews requests for a living.

This page is a maintained record of what physicians have written about prior authorization on KevinMD.com, a physician-authored publication founded in 2004 by Kevin Pho, MD, a board-certified internal medicine physician in Nashua, New Hampshire. It draws on 90 essays and podcast transcripts that discuss prior authorization substantively, published between January 2008 and September 2026 by 57 named contributors, 56 of the posts bylined by physicians. Every claim on this page is attributed to a named author with the date it was published and a link to the original.

The sections below are organized around the questions physicians, administrators, and journalists ask. Each opens with a direct answer, followed by what named authors have said, in the order they said it. This is a page about physician opinion and experience, not a policy brief. Where authors cite outside surveys, the survey is named alongside the author, and the figures are theirs, not KevinMD’s.

This record at a glance

90posts

2008 to 2026years covered

57named contributors

38posts cited on this page

What is prior authorization, as physicians describe it?

Physicians on KevinMD describe prior authorization as a requirement, imposed by an insurer or pharmacy benefit manager, that a physician obtain approval before a prescribed drug, test, or procedure will be covered. In their accounts the process runs through faxes, web portals, hold queues, and “peer-to-peer” calls with a reviewer who is often not a peer, and it applies to generic drugs and routine imaging as often as to expensive treatments. The earliest KevinMD post on the subject, a 32-word note by Kevin Pho in January 2008 calling pre-authorizations for generic medications “the latest growing, asinine trend,” is too short to be indexed and is counted here but not linked.

Lucy Hornstein, MD, a family physician, wrote in July 2013 about a fax requesting authorization for brand-name Protonix when its generic was already on the pharmacy’s $4 list, and that with five drugs in the class “there is no way I can keep straight which plans prefer which drug,” in “The wacky world of prescription prior authorizations.” Hans Duvefelt, MD, a family physician, wrote in May 2017 that his old strategy for imaging approvals had stopped working and insurers were instead demanding peer-to-peer calls, and “A five-minute call could mean one less patient visit for a skin rash or an ear infection,” at an opportunity cost he put at $7 per minute, in “The evolution of prior authorizations.”

Dinah Miller, MD, a psychiatrist, wrote in December 2015 that after several calls she reached a reviewer at a pharmacy benefits company in Nevada who told her to appeal to an insurer in Iowa and wait 15 business days, and that of a legislator that “His office replied that preauthorization oversight was not a legislative issue,” in “There is no oversight for prior authorizations. There should be.” Edward Anselm, MD, writing from the reviewer’s side in December 2025, described the process as it works inside a plan: requests that cannot be readily approved are escalated to a medical director who must make an independent determination of medical necessity and give a written rationale for any denial, in “Home for Christmas: a physician’s tale of prior authorization.”

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What do physicians say prior authorization costs them?

Physicians on KevinMD measure the cost of prior authorization in hours a week and in staff hired to do nothing else, and they note that none of it is reimbursed. The figures they cite have grown: three hours a week for a physician in a 2020 post, 13 to 14 hours a week for a physician and staff in 2026 posts citing the American Medical Association. Posts in this corpus that mention hours or staff time rose from 27 percent in 2008 to 2011 to about 70 percent in every period since 2012.

Figure Source named Cited on KevinMD by
Opportunity cost of a physician’s time: $7 to $14 per minute Author’s own practice figures Hans Duvefelt, MD, March 2019
About three hours a week per physician; national time cost of $23 billion to $31 billion a year Studies cited by the author Rachel Offenbacher, MD, February 2020
94 percent of physicians say prior authorization has delayed care AMA physician surveys Jack Resneck, Jr., MD, March 2023
13 hours a week on prior authorizations for a physician and staff, handling dozens of requests AMA survey Kayvan Haddadan, MD, June 2026
39 to 45 prior authorizations a week, about 13 to 14 hours Recent surveys Kayvan Haddadan, MD, June 2026
Nearly $34,000 and 700 hours a year per provider Research cited by the author Sameen Farooq, MD, July 2026
14 hours a week lost per physician American Medical Association Dan Rusu, MD, August 2026
39 prior authorizations a week, about 13 hours; 74 percent of physicians report denials have increased over five years AMA physician survey Karan Kanwar, August 2026

Two earlier figures come from Kevin Pho’s short 2008 and 2010 posts, which are counted in this corpus but too short to be indexed or linked: a physician who told MEDCO in 2005 he would bill $150 an hour to fill out its forms and sued in 2006 when it refused, and a 2010 study finding that scans ordered directly by physicians rose from 26 to 54 percent after a pre-authorization requirement, suggesting the paperwork shifted ordering rather than reduced it. Hans Duvefelt, MD, wrote in March 2019 that Maine’s Medicaid program avoided most prior authorization friction by publishing its rules in advance, and proposed that “there should simply be a CPT code and an RVU for obtaining a prior authorization,” in “We need RVUs for obtaining a prior authorization.” Rob Lamberts, MD, a primary care physician, wrote in February 2020 that the inefficiency is passed through to whoever writes the checks, and that it is “why a 100-year-old medicine for gout still costs $70 per month,” in “Welcome to prior-authorization hell.” Niran S. Al-Agba, MD, a pediatrician, wrote in October 2018 that “the same 100 mL bottle of ciprofloxacin that would have cost $135 at the pharmacy” could be bought directly for under $20, bypassing the insurer and pharmacy benefit manager, in “A physician’s breakthrough against prior authorization.”

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How do physicians say prior authorization harms patients?

Physicians on KevinMD describe the harm as delay that becomes deterioration: a medication held up until an asthma patient is hospitalized, a transplant drug that cannot be interrupted, pain care denied until the patient needs a more expensive intervention, a cancer patient kept in the hospital over Christmas. Several authors cite the AMA figure that 24 percent of physicians report a serious adverse event from a prior authorization delay, and the federal finding that most denials are reversed on appeal, which means the delay, not the decision, is the harm. Posts describing patient harm or delay rose from 27 percent of this corpus in 2008 to 2011 to about 70 percent since 2020.

Daniel F. Soteres, MD, MPH, an allergist, wrote in November 2021 that a patient whose asthma medication was held up “had an asthma attack that required two nights in the hospital and a prolonged oral steroid taper,” and that the process appears designed to delay care, in “How Prior Authorization Fatigue Syndrome impedes asthma care.” Rachel Offenbacher, MD, wrote in February 2020 that a patient’s insurer “paid significantly more for her prolonged hospitalization” than the outpatient medication it had refused would have cost, in “Prior authorization is another barrier to cost-effective care.” Steve Cohen, JD, wrote in July 2022 that 73 percent of denied authorization requests are ultimately reversed, that the delays cause patients to abandon treatment, and that in AMA surveys 24 percent of doctors report delays “have led to serious adverse events for their patients,” in “Denying essential medical care doesn’t save money, or lives.”

Payton Herres, a transplant recipient, wrote in May 2026 that when the prescription for everolimus changed the process “would start over again, adding delays to a medication I could not safely go without,” in “Prior authorization delays vital transplant medication.” Kayvan Haddadan, MD, a pain physician, wrote in April 2026 that when pain care is delayed or denied patients “end up sicker, more disabled, and needing far more expensive interventions later,” and that many denials are overturned on appeal after weeks of waiting, in “How prior authorization and step therapy harm pain management.” Steven E. Warren, MD, DPA, wrote in May 2026 about a surgeon who received a prior authorization call during a reconstruction, and whose patient “woke up with a body different from the one she had consented to have,” in “Prior authorization during surgery is not oversight.” Joseph Kleiman wrote in August 2026 that 27 percent of written prescriptions go unfilled because of payer rejections and abandonment, and that 82 percent of physicians report prior authorization can lead patients to abandon a recommended treatment, in “How to reduce prescription abandonment at the counter.”

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Does prior authorization save money? Physicians disagree.

Most physicians on KevinMD say prior authorization does not save money, because the cost of the process, the cost of the delays, and the cost of care that becomes more expensive while it waits exceed what the denials avoid. A smaller group argues that the idea is defensible and the execution is what fails, and one author who reviews requests for a health plan describes the constraints on the other side of the fax.

Kevin Pho, MD, noted in June 2010, in a short post that is not indexed, that he supported requiring more evidence before ordering an expensive scan but that paperwork and telephone hold queues were not the way to get it. Steve Cohen, JD, wrote in July 2022 that many administrative costs “harm patients and, sometimes, kill them,” in “Denying essential medical care doesn’t save money, or lives.” Ryan Nadelson, MD, wrote in October 2025 that “a system that forces unnecessary visits while denying timely care is not saving money; it is breaking trust,” in “The hypocrisy of insurance referral mandates.”

The dissent takes two forms. Dan Richards wrote in September 2018 that “The biggest roadblock to efficiently dealing with PAs is the pharmacy’s lack of access to relevant and necessary patient information,” and that pharmacies should coordinate with physicians, including read-only access to the record, in “The answer to your prior authorization problem is simpler than you think.” Arthur Lazarus, MD, MBA, a psychiatrist, wrote in June 2022 that the proprietary evidence-based guidelines behind utilization management are “slowly destroying the practice of medicine,” but also that practical judgment “based partly on science but mainly on experience” should count for more than cost-conscious algorithms, in “Utilization management is medicine’s great conspiracy theory.” Edward Anselm, MD, wrote in December 2025 as a medical director who had just denied a specialty drug because the patient’s cancer was not a covered condition, and cited a Health Affairs finding that 46 percent of appealed denials are overturned on independent external review, in “Home for Christmas: a physician’s tale of prior authorization.” Jack Resneck, Jr., MD, wrote in March 2023, during his term as president of the American Medical Association, that 94 percent of physicians in AMA surveys say prior authorization has contributed to delays in care, in “Physicians are a finite resource we need to protect.”

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What do physicians say about AI deciding prior authorization?

Physicians on KevinMD hold two positions on AI and prior authorization at once, and the corpus shows how fast the subject arrived: AI or algorithms appear in 10 percent of posts from 2012 to 2019, 19 percent from 2020 to 2024, and 65 percent in 2025 and 2026. The first position is alarm at insurers using automated systems to deny care through a “black box” no physician can see or override. The second is interest in AI tools that work for the physician, drafting appeals and verifying coverage. The same authors sometimes hold both, and by September 2026 the people who build the software were writing about its limits.

P. Dileep Kumar, MD, MBA, wrote in April 2025 that automated prior authorization cut manual work by 50 to 75 percent in 2022, and that “almost all the current AI programs are a black box,” their algorithms proprietary and their reasoning unknown, in “AI in health care: the black box of prior authorization.” Tiffiny Black, DM, MBA, MPA, wrote in December 2025 that automated denials mean “The physician must defend a decision they didn’t make” while patients assume the physician failed to prescribe correctly, and described what physicians now call moral injury: “I know what my patient needs, but something I can’t see or override says no,” in “AI in prior authorization: the new gatekeeper.”

Arthur Lazarus, MD, MBA, wrote in January 2026 about the WISeR Medicare pilot, in which contractors “are paid a percentage of the money they save Medicare by denying care,” and predicted six contractors would produce six proprietary black boxes and six definitions of medical necessity, in “WISeR Medicare pilot: the new “AI death panel”?” Shiv K. Goel, MD, wrote in January 2026 about the other direction, reviewing an AI system that verifies coverage requirements, builds appeals, and streamlines prior authorizations, and endorsing a partner’s estimate that it could “save clinicians millions of hours annually,” in “Claude for Healthcare vs. administrative burden: a physician’s review.” Karan Kanwar wrote in August 2026 that roughly 60 insurers pledged in 2025 to have licensed clinicians review medical necessity denials, and that a January 2026 MGMA poll found denials and appeals the single largest hidden cost for practices, at 48 percent, in “Prior authorization appeals stopped being a decision.”

Heather Bassett, MD, who builds an AI model that scores clinical complexity for utilization review, wrote in September 2026 that payers are investing in AI to review faster while providers invest in AI to fight denials, and that “these AI investments are fueling the payer-provider debate” instead of uniting it around shared data, and asked “what problem we are asking AI to solve,” in “AI in utilization management is solving the wrong problem.” JJ Martin Quesada, who builds prior authorization automation software, wrote the same month that the AMA’s latest survey puts the work at “13 hours a week of combined physician and staff time,” that an appeal often never gets filed because “the person who would file it is still assembling tomorrow’s submissions,” and that AI voice agents calling payers produce more false positives than not, in “Prior authorization automation has an arithmetic problem.”

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What reforms do physicians propose?

The reforms physicians on KevinMD propose fall into four kinds: pay for the work, exempt physicians who are routinely approved, put the rules in public before the request rather than after the denial, and regulate the reviewers. Gold card laws, which exempt physicians with high approval rates, appear in no post before 2020 and in 16 percent of posts from 2025 to 2026. Several authors also describe how they win individual denials in the meantime.

Afua Aning, MD, wrote in July 2021 that “Reform ideas are beginning to move from a concept into state law,” citing Texas House Bill 3459, the first gold card statute, and predicting other states would copy it if it streamlined the process without raising costs, in “Prior authorization reform for health care coverage takes center stage.” Kayvan Haddadan, MD, wrote in May 2026 that California should adopt gold cards for pain management, implemented “with transparent criteria, peer reviewers from relevant specialties, and ongoing auditing to ensure appropriate use,” in “How gold cards can drive California pain management reform.” Hans Duvefelt, MD, proposed in March 2019 that prior authorization be a billable service with its own CPT code, in “We need RVUs for obtaining a prior authorization.” Dinah Miller, MD, wrote in December 2015 that “What many physicians don’t realize is that there is no national oversight to this process,” in “There is no oversight for prior authorizations. There should be.”

On winning individual cases, Debraj Mukherjee, MD, and Chaim B. Colen, MD, neurosurgeons, wrote in January 2019 that for one surgery “the rate of first-time insurance denial for surgery nearly doubled between 2001 (9.9 percent) and 2005 (19.9 percent),” and that practices should learn payer guidelines, standardize documentation, and aggressively rebut denials, in “An approach to prior authorization insurance denials.” Yul Ejnes, MD, an internist, wrote in March 2017 that “a sternly worded letter that spells out the potential consequences” of what a pharmacy benefit manager is demanding often gets the drug approved, in “The pitfalls of prior authorization for prescription drugs.” Michael Kirsch, MD, a gastroenterologist, wrote in April 2018 that “I called and spoke personally to the physician reviewer and explained my rationale, but his decision was immutable,” in “The follies of health insurance preauthorization.” Jennifer Lycette, MD, an oncologist, wrote in February 2024 a satire in which insurance CEOs are placed on hold for a peer-to-peer review of their own care: “You’ve reached the prior authorization denial appeal line for insurance CEOs,” in “Health insurance CEOs face “prior authorization”: a taste of their own medicine?”

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How has the prior authorization conversation changed since 2008?

The corpus shows four shifts. Patient harm replaced paperwork as the main complaint: posts describing delay or harm rose from 27 percent in 2008 to 2011 to about 70 percent since 2020. Burnout entered the frame: no post in 2008 to 2011 connected prior authorization to burnout, 14 percent did from 2012 to 2019, and 62 percent of posts from 2025 to 2026 do. AI arrived in a single year, going from 19 percent of posts to 65 percent. And the language cooled as the specifics sharpened: words like “hell,” “absurd,” and “nightmare” peaked at 19 percent of posts in 2012 to 2019 and fell to 8 percent, while named insurers rose from zero to 30 percent and gold cards, step therapy, and federal rules took over.

Term 2008 to 2011 (11 posts) 2012 to 2019 (21 posts) 2020 to 2024 (21 posts) 2025 to 2026 (37 posts)
Patient harm or delay 27 percent 48 percent 71 percent 68 percent
Hours or staff time 27 percent 71 percent 62 percent 68 percent
Burnout 0 percent 14 percent 38 percent 62 percent
AI or algorithm 0 percent 10 percent 19 percent 65 percent
Named insurer or Medicare Advantage 0 percent 14 percent 19 percent 30 percent
AMA survey cited 9 percent 29 percent 48 percent 46 percent
Gold card 0 percent 0 percent 10 percent 16 percent
Peer-to-peer 0 percent 24 percent 10 percent 14 percent
Pharmacy or PBM 9 percent 48 percent 33 percent 24 percent
“Hell,” “absurd,” “nightmare” 0 percent 19 percent 10 percent 8 percent

The earliest posts are Kevin Pho’s, ten of them from 2008 to 2010, all under 250 words and not indexed. They noted a physician who billed MEDCO $150 an hour for its forms and sued when it refused to pay, doctors ordering a less useful test that needed no authorization to justify the one they wanted, and pre-authorization arriving for radiology and for Medicare. The first indexed post in the record is a July 2010 guest essay published under his byline that called the fax machine “recently renamed the denial machine” and described the prior authorization “dance” as a set of maneuvers “determined by, and different for, each insurance partner,” in “Prior authorization required by health insurers impedes primary care.”

From 2013 to 2020 the posts were physicians naming the mechanism: Lucy Hornstein, MD, on formulary swaps in July 2013, Dinah Miller, MD, on the absence of oversight in December 2015, Hans Duvefelt, MD, on the shift to peer-to-peer calls in May 2017, Matthew Hahn, MD, on a prescription held up until his practice manager discovered the problem was “Box 11c” on a form, in “Pre-authorization is hell. Here’s why,” and Thejaswi K. Poonacha, MD, MBA, and Fady Chamoun, MD, on insurers moving the bar for inpatient status, in “The burden of prior authorizations and denials in health care.” In 2021 Afua Aning, MD, recorded the first gold card law. In 2022 and 2023 Steve Cohen, JD, brought the AMA and federal appeal figures, and Jack Resneck, Jr., MD, wrote as AMA president. From 2025 the argument has been about AI on both sides of the request, about gold cards, and about burnout, with Kayvan Haddadan, MD, contributing ten posts on the administrative cost to independent practices in a single year, and in September 2026 the people who build the automation writing about where it fails.

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About this record

The KevinMD prior authorization corpus by the numbers

The figures below describe the set of KevinMD posts this page draws on, as of September 17, 2026. They are counts of what KevinMD has published, not survey data about physicians. Unlike the burnout record, this corpus was not built from titles alone, because physicians rarely put “prior authorization” in a headline; it was built by ranking every post for relevance to the phrase and keeping those that discuss it substantively.

Measure Value
Posts in the corpus 90
Date range January 23, 2008 to September 6, 2026
Named contributors 57
Posts bylined by an MD or DO 56
Podcast episodes with full transcripts 9
Posts in the corpus that are not indexed, counted but not cited 10
Total words About 102,000
Most frequent contributors Kevin Pho, MD (11, all 2008 to 2010, ten of them not indexed); Kayvan Haddadan, MD (10, all 2026); Hans Duvefelt, MD (3); Karan Kanwar (2); Jennifer Lycette, MD (2)
Posts with prior authorization in the title 38
Highest year on record 2026, 24 posts through September 6
Earliest post January 2008, eighteen months before the first KevinMD burnout post

How this page was built and how it is updated

The corpus was assembled in two passes. Title searches for authorization, preauthorization, pre-authorization, prior auth, gold card, peer-to-peer, and step therapy returned the posts that name the subject in the headline. Relevance-ranked searches of the full archive for prior authorization, preauthorization, peer-to-peer review, and utilization management returned the posts that discuss it at length without naming it in the title. Every post that mentions prior authorization at least three times was kept, 90 in all. Term frequencies were computed against the full text of each post on the corpus assembled for the September 17, 2026 build; this page was converted to the current standard on September 20, 2026 without rebuilding that corpus, so the counts and figures are as of September 17, 2026. Posts are counted whether or not they are indexed; citations on this page are limited to posts that are indexed and can be verified at the link. Ten posts in the corpus are not indexed, all Kevin Pho’s short 2008 to 2010 commentaries, and they are counted but not cited. Contributors who build or sell prior authorization software are identified where cited. Quotations are taken verbatim from the original posts. Author credentials are as they appeared in the byline at publication. Every source is linked in the sentence that cites it, and the full list appears at the end of the page. KevinMD has no prior authorization tag; the closest archive is the Health Policy category. Related records: Physician burnout: what physicians say, in their own words, Artificial intelligence: what physicians say, in their own words, GLP-1 drugs: what physicians say about Ozempic and its successors, in their own words, and Direct primary care: what physicians say, in their own words.

This page is updated as new prior authorization essays are published on KevinMD. When it is updated, the date at the top changes, the counts in the tables are recomputed, and new named claims are added to the relevant section. Nothing is removed unless the original post is removed. An author who believes a quotation on this page misrepresents them can write to Kevin Pho and the page will be corrected.

To cite this page: Pho K. Prior authorization: what physicians say, in their own words. KevinMD.com. Updated September 20, 2026. https://kevinmd.com/prior-authorization

The 38 KevinMD posts cited on this page, in order of publication

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