Last year, when I called UnitedHealthcare to ask why it had denied prior authorization for my father to enter rehab after the amputation of his leg, the call-center worker sounded as horrified as I was. “This is unreasonable, but I don’t know how I can fix it,” she told me.
My dad’s care team at the Johns Hopkins Hospital had prescribed a short, intensive rehab program built for amputees, but first we needed the pre-approval UnitedHealth requires before patients can receive certain care. That process proved to be a bureaucratic maze of dead-end paperwork.
With my expertise and a team of Hopkins physicians and staff helping my family, we couldn’t break through United’s paperwork prison. What chance does anyone have?
The first insurance denial cited his cancer, apparently without registering that his leg had just been removed, the whole reason he needed the rehab. The second denial said he didn’t qualify because of his progress; that “progress” was learning to hop on one leg from his hospital bed to a chair. My father’s doctors fought for his care alongside us; collectively, we spent dozens of hours trying to find anyone at UnitedHealth or its affiliate NaviHealth with the authority to make an informed, rational decision.
After being stuck in limbo in the hospital for over a week, my family gave up: not because the denial was right, but because the fight consumed time and energy my father needed to battle his cancer.
“They kind of sapped my momentum,” my father told me, wistfully. He never got that prosthetic leg. (When asked for comment about denying prior authorization, UnitedHealth said I needed power of attorney for them to able to discuss the case: “We are not legally allowed to speak about a member case without a signed release by the member or a person with power of attorney.”)
I’m a lawyer who has spent much of my career in economic policy, including health care policy. I’ve even had the honor of serving as a senior official in the White House. Yet with that expertise and a team of Hopkins physicians and staff helping my family, we couldn’t break through United’s paperwork prison. What chance does anyone have?
My family’s experience wasn’t a one-off glitch. For United, the system was working as designed. Prior authorization may have begun as a narrow cost-control tool. But as my co-author Emma Freer and I explain in a new paper, it has mushroomed into a pervasive corporate veto over care: a way for a handful of private health care conglomerates to boost profits by overriding the judgment of the physicians who actually know their patients.
We are burning a whole missing doctor workforce on paperwork designed chiefly to wear people down.
The conflict of interest isn’t subtle. These insurance companies increasingly own the very entities that adjudicate the requests, and they make money every time they say “no” — even to medically necessary care, and increasingly by handing the decision to AI. (In a follow-up statement, UnitedHealth added, “Our approach to post-acute care is centered on helping members receive the right care, at the right time, in the most appropriate setting….We follow Medicare coverage requirements, CMS regulations and guidance, plan benefits, and nationally recognized evidence-based clinical criteria.”)
Prior authorization now consumes the equivalent of more than 99,000 full-time clinicians’ worth of time each year at a cost of as much as $32.7 billion annually, extrapolating from the government’s own data. That’s lost capacity equivalent to more than the entire physician shortage our country faces. We are burning a whole missing doctor workforce on paperwork designed chiefly to wear people down.
To see the profit motive at work, compare the use of prior authorization in traditional Medicare versus Medicare Advantage, the privatized version. Publicly operated Medicare adjudicated about 625,000 requests (0.02 per enrollee) in a single year. In Medicare Advantage, private insurers adjudicated nearly 53 million prior authorization determinations (1.7 requests per enrollee), despite covering a similar population and having similar coverage criteria.
Medicare Advantage’s extensive use of prior authorization didn’t make it cheaper. Despite imposing much more stringent prior authorization requirements, Medicare Advantage plans cost taxpayers 22% more per patient than traditional Medicare that year, a difference of $83 billion.
And as my family is painfully aware, the costs aren’t just monetary – they’re devastatingly human. More than one in four physicians say prior authorization has led to a serious adverse event for a patient in their care — i.e., a hospitalization, a life-threatening event, or a patient’s permanent disability or death.
Yet Washington keeps reaching for half-measures: voluntary industry “pledges” and narrow fixes that have barely made a dent in the practice. These policies fail for the same reason every time: As long as an insurer profits from every denial, it will keep denying.
Prior approval should be allowed only in rare, well-documented cases of genuine overuse of the treatment or device.
The fix has to be structural, eliminating the financial conflict at the root. Congress and the states should bar health insurance conglomerates from owning or affiliating with the companies that adjudicate their prior authorization requests, or from adjudicating them in-house. Prior approval should be allowed only in rare, well-documented cases of genuine overuse of the treatment or device — and even then only when adjudicated by an independent third party, under a hard time limit, with a real doctor-to-doctor conversation and a flat ban on AI-based denials.
Insurers will warn this will raise premiums. Be skeptical. The main study they cite was commissioned by the insurance industry itself, and it ignores the enormous administrative savings from ending prior authorization, along with the cost of patients getting sicker while they wait. That means they’re ignoring over $32 billion in savings in their calculus. And to repeat: traditional Medicare, which uses prior authorization sparingly, costs less than the private plans that lean on it heavily.
When I asked my father whether I could tell our story publicly while his fight was still ongoing, he said no. Though he spent his life, as a professor and activist, speaking truth to power, he was afraid United would retaliate while he still needed the insurer to cover his cancer treatment. That fear is its own indictment of a system that puts the lives of desperately ill people in corporate hands, and counts on them being too sick and too scared to push back.
My father died in February, having spent his final few months in a wheelchair. So I’ll say it plainly on his behalf now: no company should be allowed to make money by denying Americans the care their doctors say they need. It’s time to ban prior authorization as we know it.
This piece is dedicated to the author’s father, Michael L. Monheit (1946–2026). The American Economic Liberties Project is collecting stories of others who have been denied care via prior authorization.
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