There is a good reason for health insurers to occasionally require prior authorization for medical treatment. If a doctor prescribes an unusual, experimental, or expensive medication or procedure, the insurer can make sure the care is appropriate or suggest a cheaper, equally effective treatment.
The problem, however, is that prior authorization has expanded over the years to require approval for a much wider range of care, from generic drugs to office visits, than is really necessary. According to the Massachusetts Division of Insurance, there were approximately 1.58 million prior authorization requests submitted in 2024 on behalf of the approximately 1.3 million people covered by Massachusetts-regulated commercial insurance plans. The Division’s survey of 14 Massachusetts insurers found they required prior authorization for anywhere from 2,600 billing codes to nearly 13,000.
The need to obtain prior authorization can delay patients from getting care they urgently need and put an unnecessary administrative burden on clinicians.
Governor Maura Healey’s announcement last week that she will limit insurers’ ability to require prior authorization for certain types of care — like chronic disease management and urgent care — is an important step to improve patients’ access to timely health care. As Healey put it at a State House press conference, “We’re cutting the red tape that stands between you and health care.”
But as the Division of Insurance undergoes the regulatory review process, regulators must ensure that insurers still have authority to require approval for those unusual or expensive treatments that drive up health care costs.
For example, a patient shouldn’t need prior authorization for common treatments for chronic diseases like an insulin pump for diabetes or an inhaler to treat asthma. But there should be a mechanism to ensure that someone prescribed an expensive GLP-1 drug actually has diabetes or obesity, or a cancer patient has a clinical need for an expensive oncology drug if a cheaper one is available.
They also shouldn’t need to submit the same requests twice. Ashley Blackburn, interim executive director of Health Care for All, said the organization’s consumer helpline often gets calls from patients who have a prior authorization but switch insurance plans and have to delay their care while reapplying.
Overall, the regulatory burden posed by prior authorization is high. A national report by the Council for Affordable Quality Health Care found the medical industry nationally spent $1.3 billion on prior authorization in 2023. Providers spent, on average, 11 or 16 minutes per transaction, depending on how it was submitted.
In addition to the financial cost, prior authorization may play a role in doctor burnout. A 2023 Massachusetts Medical Society report on physician well-being found 58.2 percent of physicians listed prior authorization as a top workplace stressor. “They make us jump through these hoops for every little thing,” Massachusetts Medical Society president Olivia Liao told the editorial board. “It became a game of ‘Mother may I.’ ”
The insurance industry says prior authorization saves money and ensures consumers don’t get unnecessary or harmful care. The industry commissioned a study released in 2023, which found that eliminating prior authorization entirely would raise premiums nationally by more than $28 to $37 per member per month due to the cost of unnecessary care.
Striking a balance between eliminating regulatory burdens and providing a check on unnecessary care should involve determining which services warrant prior authorization and which do not — which is what Healey’s new rules seek to do. A report from the Division of Insurance, released in conjunction with the new regulations, found that there are prior authorization requests that insurers approve almost universally. Of 35,500 requests for outpatient physical, speech, or occupational therapy in 2024, insurers approved 98.1 percent. Insurers approved more than 90 percent of requests for inpatient care, behavioral health office visits, outpatient ambulatory surgery, and durable medical equipment.
As Healey said at the press conference, it doesn’t make sense for thousands of patients to delay treatment while awaiting the outcome of a request that’s approved 9 out of 10 times.
Healey’s proposed regulations would prohibit insurers from requiring prior authorization for several broad categories of services: emergency services and in-network urgent care; inpatient acute care; primary care and preventative care; chronic disease management; maternity and abortion care; outpatient substance use services; and in-network physical, occupational, and speech therapy.
The regulatory review process, which includes a Feb. 19 public hearing, should provide an avenue to ensure those are the right services. For example, while it’s important to ensure people don’t face barriers to getting substance use treatment, there is a history of insurance fraud in that field, and some checks may be needed to ensure claims are legitimate.
Once the rules become effective, they will require insurers to respond to urgent requests within 24 hours. If a patient switches insurers, the new insurer will have to honor prior authorizations from their previous insurer for three months. There is a “safety valve” letting insurers reinstate prior authorization if utilization of a service spikes.
The rules only apply to state-regulated commercial insurers, although companies that self-insure could choose to follow similar rules. A MassHealth spokesperson said the state Medicaid program will align with the same framework.
The health care system today is far too complicated. Limiting the use of prior authorization to a more limited slate of services will make getting and giving care a little simpler for patients and providers.
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