Cite as: Nangunuri B, Elmofty D. The burden of prior authorizations in pain medicine: a call for reform. ASRA Pain Medicine News 2025;50. https://doi.org/10.52211/asra080125.011

Prior authorization (PA) has increasingly become a significant challenge in pain medicine. Originally introduced in the 1980s as a tool for controlling healthcare costs, PA enables insurance companies to determine whether specific treatments or medications are deemed necessary and covered.¹ While intended to curb unnecessary healthcare spending, this process has since morphed into a bureaucratic barrier that affects both patients and healthcare providers. Instead of streamlining care, it often results in significant delays, particularly in fields such as pain management, where timely treatment is essential. These prolonged wait times and frequent denials not only worsen patient health outcomes but also add to the administrative load on providers. This article outlines the profound effects of PA on pain management, emphasizing the urgent need for reform.

Research continues to highlight the detrimental effects of PA on patient outcomes. By 2021, 34% of physicians reported that PA-related delays or denials led to serious adverse events, including unnecessary hospitalizations (24%), life-threatening conditions (18%), and even cases of death or permanent disability (8%).² A 2024 study from Memorial Sloan Kettering found that 22.6% of patients whose PA requests were denied required emergency room visits or hospitalizations for treatment of pain crises.³ These statistics underscore the harm PA delays cause, which not only degrades patient well-being but also contributes to higher healthcare costs through preventable hospital admissions. This issue is especially troubling in pain management, where prompt care can be the difference between manageable symptoms and long-term suffering.

PA processes disproportionately target high-cost medications and treatments, particularly medications such as opioids that are commonly used for managing chronic pain.¹ Patients requiring long-acting opioids, such as fentanyl or oxycodone, frequently face delays or outright denials, further complicating their pain management. Cancer patients, in particular, bear a heavy burden. In a study by Chino et al., it was revealed that 1 in 20 PA requests for cancer pain treatments were denied, leading to uncontrolled pain and heightened distress.³ For patients undergoing cancer treatment, where pain management is a vital component of care, these delays can significantly worsen their quality of life and impede overall treatment progress. Many patients are also forced to seek alternative therapies or pay out-of-pocket, deepening the negative impact of PA-related delays.

One of the most frustrating challenges for healthcare providers is the lack of standardized guidelines across insurance plans. Each insurance company, whether Medicare, Medicaid, or private insurers, has its own unique set of criteria for PAs often leading to inefficiencies and confusion.⁴ A study by Berman et al. found that only 33 out of 50 surveyed insurance companies had publicly available PA guidelines, and many of these guidelines lacked evidence-based support.⁴ This creates an unpredictable system for providers, adding more layers of complexity to the already challenging PA process and further delaying patient care.

In addition to the lack of uniform guidelines, the administrative burden of PAs is substantial. Providers often need to navigate different submission and approval processes for each insurance company, which adds to their already heavy workload. This has a direct impact on physician burnout, with a 2019 American Medical Association (AMA) survey reporting that 86% of physicians experienced significant burnout due to the administrative demands of PA.⁵ Physicians are spending, on average, 2 full business days each week dealing with PA requests, a burden that takes away from patient care.⁵ The financial cost is also staggering. The Cleveland Clinic estimates that PA adds approximately $10 million annually to healthcare expenses.⁵ These burdens contribute to reduced efficiency and decreased quality of care for patients.

One of the most frustrating challenges for healthcare providers is the lack of standardized guidelines across insurance plans. Each insurance company, whether Medicare, Medicaid, or private insurers, has its own unique set of criteria for PAs often leading to inefficiencies and confusion.

Efforts to address these issues have been ongoing. In 2011, the AMA began advocating for the standardization of PA processes and even proposed eliminating PAs altogether, arguing that clinicians are best positioned to determine the care their patients need.² Since then, several states have introduced legislation aimed at reforming PA. Michigan’s Bill No. 247, for example, mandates a standardized electronic PA process, while states such as Delaware have pushed for greater transparency around which services require PA.² "Gold card" laws in West Virginia and Texas, which allow physicians with a high volume of PA approvals to bypass the process for six months, represent promising steps toward reducing the administrative burden.² However, widespread implementation remains a challenge.

ASRA Pain Medicine has been a strong advocate for providers dealing with the challenges of PA in pain medicine. In 2021, ASRA Pain Medicine submitted recommendations to the Centers for Medicare and Medicaid Services (CMS), urging the expansion of "gold card" programs and the development of document requirement lookup tools to streamline PA requests.⁵ ASRA Pain Medicine continues to work with organizations such as the AMA to promote coordinated advocacy efforts in this space. The AMA’s 21 principles for PA reform, which emphasize transparency, fairness, timely access, administrative efficiency, and clinical validity, offer a comprehensive framework for addressing the core issues of the current PA process.⁶

Recent legislative efforts demonstrate positive momentum in addressing the burdens of prior authorization. The Alternatives to PAIN Act, introduced in the Senate in February 2025, aims to expand access to non-opioid pain management options by requiring insurance coverage without a deductible and prohibiting prior authorization and step therapy for these treatments.⁷ This legislation is part of a broader initiative to reduce opioid reliance by improving access to safer, effective alternatives.⁷

Additionally, CMS finalized the Interoperability and Prior Authorization Final Rule in January 2024.⁸ This rule is designed to improve the electronic exchange of healthcare data and streamline the prior authorization process to keep care patient-centered.⁸ It requires impacted payers, including Medicare Advantage and Medicaid managed care plans, to implement a Patient Access API and a Prior Authorization API by 2027.⁸ The Patient Access API will allow patients to track the status of their prior authorizations through third-party applications.⁸ The Prior Authorization API will enable providers to determine whether a prior authorization is required, identify necessary documentation, and submit requests directly through patients’ electronic health records.⁸ These changes aim to automate and simplify the submission process, increase transparency, and reduce the administrative burden on healthcare providers.

Emerging technologies, such as artificial intelligence (AI), present potential solutions to the inefficiencies of PA. A study by Vatsal et al. explored the use of AI tools, including GPT, to assist in validating PA requests, aiming to expedite the process and reduce the administrative load on clinicians.⁹ Their research found that a novel technique known as implicit retrieval augmented generation outperformed other AI models by retrieving relevant text segments to aid in decision-making.⁹ As AI continues to advance, it promises to significantly reduce PA delays, improve the timeliness of patient care, and ease the administrative burden on healthcare providers. Implementing AI solutions has the potential to make the PA process more efficient and less burdensome for all involved.

The current PA system in pain medicine is fraught with delays, inconsistencies, and unnecessary administrative challenges, all of which negatively affect both patient outcomes and provider efficiency. Data clearly show that reform is necessary to minimize these barriers and ensure timely, effective care. By streamlining the PA process, establishing uniform guidelines, and harnessing the potential of emerging technologies like AI, we can reduce the administrative burden on providers and improve the quality of care for patients. These reforms are essential for addressing not only the unique challenges of pain management but also broader issues, such as healthcare access and physician burnout. Reforming PA is a critical step toward building a more efficient and patient-centered healthcare system.

References

1. Gupta R, Fein J, Newhouse JP, et al. Comparison of prior authorization across insurers: cross-sectional evidence from Medicare Advantage. BMJ 2024;384:e077797. https://doi.org/10.1136/bmj-2023-077797
2. Hanel A. The pain of prior authorizations: consequences of the de-prioritization of human life in favor of cost containment. 23 Hous J. Health L. & Pol’y 2024;23:43-77. https://houstonhealthlaw.scholasticahq.com/article/93895-the-pain-of-prior-authorizations-consequences-of-the-de-prioritization-of-human-life-in-favor-of-cost-containment
3. Chino F, Persaud S, Jinna S, et al. Payor denial after prior authorization request for long-acting pain medication: provider and patient perspectives. JCO 2024;42:11004. https://doi.org/10.1200/JCO.2024.42.16_suppl.11004
4. Berman D, Holtzman A, Sharfman Z, et al. Comparison of clinical guidelines for authorization of MRI in the evaluation of neck pain and cervical radiculopathy in the United States. J Am Acad Orthop Surg2023;31(2):64-70. https://doi.org/10.5435/JAAOS-D-22-00517
5. Viscusi E. Reducing the burden of prior authorizations to aid patient care delivery. ASRA News.https://www.asra.com/news-publications/asra-update-item/asra-updates/2021/01/05/reducing-the-burden-of-prior-authorizations-to-aid-patient-care-delivery. Published January 5, 2021. Accessed December 18, 2024.
6. Prior authorization reform initiatives. American Medical Association. https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-reform-initiatives. Accessed December 18, 2024.
7. Alternatives to PAIN Act: S. 475. 119th Congress. https://www.congress.gov/bill/119th-congress/senate-bill/475/all-info. Published February 6, 2025. Accessed November 2024.
8. Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible Clinicians, and Eligible Hospitals and Critical Access Hospitals in the Medicare Promoting Interoperability Program, Final Rule. Federal Register. https://www.federalregister.gov/documents/2024/02/08/2024-00895/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability. Published February 8, 2024. Accessed November 2024.
9. Vatsal S, Singh A, Tafreshi S. Can GPT improve the state of prior authorization via guideline-based automated question answering? arXiv:2402.18419 [cs.CL] 2024; 147-58. https://doi.org/10.48550/arXiv.2402.18419