Doctors, patients, insurers all frustrated with prior authorization, RFK Jr. and Dr. Oz say

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The time is now to change the prior authorization (PA) process that has become an administrative pain point across the U.S. health care system.

Health and Human Services Secretary Robert F. Kennedy Jr. joined Centers for Medicare & Medicaid Services (CMS) Administrator Mehmet Oz, MD, MBA, to announce health insurers are taking action to change the process for physicians and other clinicians to ask for approval for medical tests and procedures before they can do those with patients.

Robert F. Kennedy Jr.
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Pre-authorization has become the number one complaint of physicians and patients in health care, Oz said. A full 85% of Americans say PA has affected them in a way they wish it hadn’t. Millions of people in Medicare Advantage plans have requests denied initially. Physicians spend an average of 12 hours a week dealing with 40 prior authorizations and paperwork in general.

Mehmet Oz, MD, MBA
_{© Centers for Medicare & Medicaid Services}

“It frustrates doctors. It's sometimes results in care that is significantly delayed. It erodes public trust in the health care system. It's something we can't tolerate,” Oz said.

Under Kennedy’s leadership, the administration has been expressing its frustration and for a good reason, Oz said. It’s also frustrating to people who go into the health insurance industry with the right motivations, and many of them are ready to improve it, he added.

Oz cited the biblical Beatitude that the meek shall inherit the earth. Meekness is not weakness, he said, but willingness to sheathe a dangerous sword and do good instead. Insurance companies and hospital systems have agreed to sheathe their swords, be meek, and come up with a better solution to a problem that now plagues the industry.

What’s coming

Along with the press conference that was held live in Washington, D.C., and webcast, HHS published an announcement with plans. The officials also met June 23 in a roundtable meeting with health insurance executives.

Participating health insurers have pledged to:

• Standardize electronic prior authorization submissions using Fast Healthcare Interoperability Resources (FHIR®)-based application programming interfaces.
• Reduce the volume of medical services subject to prior authorization by Jan. 1, 2026.
• Honor existing authorizations during insurance transitions to ensure continuity of care.
• Enhance transparency and communication around authorization decisions and appeals.
• Expand real-time responses to minimize delays in care with real-time approvals for most requests by 2027.
• Ensure medical professionals review all clinical denials.

A patient’s perspective

Oz and Kennedy brought some patient perspective to the news conference. Actor Eric Dane, known for his roles including playing Dr. Mark Sloan on Grey’s Anatomy, has publicly disclosed his diagnosis with amyotrophic lateral sclerosis. He was invited to the podium to speak.

“When that diagnosis hits and you find out that you're sick, your life becomes filled with great uncertainty,” Dane said. “And the worst thing that we can do is add even more uncertainty for patients and their loved ones with unnecessary prior authorization. Anything we can do to give patients more certainty with fewer delays is a worthwhile endeavor.

“I've been fortunate and have the means to access great care. I'm lucky,” Dane said. “Not everyone is in the same position. I am acutely aware of that. I applaud the insurance industry coming together with officials from CMS and HHS to take these steps in the right direction. Today is about all those who need more certainty, faster answers, and more hope for recovery.”

‘Streamline and improve our health care’

Oz and Kennedy were flanked by two congressional physicians: Sen. Roger “Doc” Marshall, MD (R-Kansas), and Rep. Greg Murphy, MD (R-North Carolina).

Marshall, an obstetrician-gynecologist, described a patient whose scheduled infertility surgery was canceled the day it was scheduled due to PA. The process has become increasingly onerous because of constantly changing requirements, often demanding more time to navigate the red tape than to complete the pre-surgery medical workup, he said.

“Today, by having all the players in the room, we hope to see a common-sense solution to streamline and improve our health care system,” Marshall said. “We must prioritize patients’ health over corporate profits and arbitrary cost-cutting measures.

“For nearly my entire time in Congress, I fought to reform the prior authorization process in Medicare Advantage,” Marshall said. “Today's event moves us closer to that goal, ensuring patients receive timely, life-saving, and health restoring care.”

‘How did we end up here?’

At the podium, Murphy asked: “How did we end up here? I think that's a real question.”

The doctor-patient bond is one of the most sacred anywhere, said Murphy, a urologist and surgeon, but PA puts somebody between them.

Confronting PA, physicians must assume some blame because there are physicians who over-order tests, Murphy said. “I think we have to get in part of our calculus better taught in medical school and in residencies. Why are you doing this. Why are we doing this?” he said. “But that's not where I'm going to put the major blame.”

Rather, there are people who have gamed the system pursuing profits, Murphy said. When consulting insurers, physicians also must be able to speak with a peer who is reviewing treatment request with expertise in the specialty of the ordering doctor, he said.

Murphy thanked the insurance companies for their willingness to work with the administration, but he added as a surgeon, he is a skeptic.

“The proof is going to be in the pudding. Are they really going to step up and do things, or are they doing something to placate an audience?” Murphy said.

Still a need for PA

Prior authorizations won’t disappear totally. There are up to 3,000 procedures that probably should have pre-authorization to ensure patients are getting the right care for the right indication by the right physician, Oz said, using an example of a knee arthroplasty.

But insurance companies should narrow down the scope of pre-authorization to address the ones most likely to be abused, he said.

Oz asked Center for Medicare Administrator Gerard “Chris” Klomp, for more procedures, and Klomp used the examples of a colonoscopy, cataract surgery, and two-day stay vaginal delivery as procedures that would be less likely to be abused.

“I think the bigger point and what we're more focused on is the process and the principles by which appropriate care is determined,” Klomp said. He used another example of an episode of care that might require two different imaging studies and three different diagnostic studies in sequence. The status quo for many insurers would be to have each one individually authorized.

“That’s illogical,” Klomp said. If that procedure requires prior authorization at all, it should be done once, quickly, almost invisibly to the patient. He also emphasized the lack of standards of communication across health care, so interoperability and standardizing processes will dramatically change the patient experience.

Prior attempts at reform

During questioning, Oz acknowledged previous industry pledges to change. Two things have changed, he said.

“I mean, there's violence in the streets over these issues,” Oz said. It was an apparent reference to the shooting of UnitedHealthcare CEO Brian Thompson, 40, in New York in December 2024.

“This is not something that is a passively accepted reality anymore. Americans are upset about it,” Oz said. The industry also sees much of the PA process is wasting time and money in an era with technology to create an interoperable system that benefits insurers, doctors and patients.

The administration has legislation to codify rules about prior authorizations, and Marshall and Murphy agreed they would support it.

“But the most important reality is, the administration has made it clear we're not going to tolerate it anymore, so either you fix it, or we're going to fix it. And I think they wisely have decided they should fix it. I'm looking forward to seeing the results,” Oz said.