Not long ago, I attended Sunday dinner at my cousin’s house. A guest shared that one of her grandson’s Little League teammates was having difficulty navigating the health care system.
The boy waited months for an important surgery, and it was canceled at the last minute. His mother, who has limited English proficiency, had difficulty getting answers as she navigated back and forth between providers, learning at each turn that appointments would be rescheduled, another test was needed, or an approval was required. To make matters worse, the boy was reluctant to return to school after being teased by other students about the mass on his neck, which required surgical removal.
Trust Is Vital
For our 30th anniversary, we’ve invited health care leaders and experts to share solutions for building trust at all levels of the system. The views expressed in this series are those of the authors and do not necessarily reflect policies or opinions of the California Health Care Foundation.
The family’s experience is not unusual. For many Californians, the struggle to access covered medical services is real, commonplace, and corrosive.
Complicated rules and disruptive handoffs create barriers to crucial information, delay care, drive up costs, and erode trust. According to a recent CHCF poll, 72% of Californians say ease of navigation meaningfully affects their trust in the health care system.
When barriers arise, it can feel like the rules themselves are the problem; that in a better system, referrals, networks, and prior authorizations would not exist. But I have spent my career inside these systems, and I don’t believe that to be the case.
Why Prior Authorization Exists
Take prior authorization, a process that is often the target of frustration. It affects no more than 15% of covered medical services. Rather than blocking patients from getting care, prior authorization helps make sure members get the right care in the right place at the right time.
Prior authorization mitigates the harm that can be caused to patients who receive care they don’t need by ensuring that treatment is safe, effective, and aligned with evidence-based medical guidelines. It also steers people toward in-network providers, encourages the pursuit of equally effective lower-cost treatment options, and helps avoid repeat care. Without it, medical care would become more expensive for everyone.
The key issue is not that plans review what gets covered. It’s that every plan does it differently.
The Real Problem Is Variation, Not Review
A physician’s office typically treats patients covered by a variety of health plans, and each plan has its own requirements, criteria, forms, and submission processes for reviewing proposed procedures. As a result, providers’ office staff members must navigate multiple sets of rules, often for the same type of care.
This complexity creates opportunities for errors, whether it’s submitting the wrong form or leaving out required information. These discrepancies can delay approvals, compounding the challenges for providers and their patients.
Variation across health plans increases the administrative burden, which strains providers at busy clinics, hospitals, and emergency departments. Faced with a patient struggling to navigate the complex health care system, clinicians and staff may understandably direct them to call their insurance company or get a referral. In the moment, that may seem like the most practical next step, but it can leave patients with more questions than answers and prolong their uncertainty.
At my cousin’s dinner, the worried grandmother told me she never called the health plan’s member services line about her grandson’s surgery because she was unaware that a member services department even existed. These misunderstandings directly affect patient health.
With only 33% of Californians saying they trust health insurance companies, it’s painfully obvious that we need to change course. That means keeping the principles of the guardrails we have in place, while streamlining them into a uniform pathway that protects patients and keeps costs in check.
What L.A. Care Changed
At L.A. Care Health Plan, we took a hard look at what we were asking providers to submit. We identified where authorization was hindering progress without adding value. In the end, we eliminated prior authorization requirements for 24% of our service codes, including specialty visits, lab and radiology procedures, and medical equipment.
Now, our providers face fewer administrative obstacles. Our members have fewer potential delays. Our physicians have greater flexibility to make timely, medically appropriate decisions.
We are also expanding our reliance on electronic prior authorization to accelerate approvals, reduce paperwork, increase transparency, and help patients get the care they need sooner. To that end, we are investing in technologies that integrate prior authorization processes with electronic health records. L.A. Care is partnering with vendors that deliver these capabilities, collaborating with plans to standardize data and authorization submission elements, and providing training and incentives for providers to use them.
But there is more to be done. Along with other health plans, we have committed to honoring authorizations for members who switch plans, responding to electronic prior authorization requests in close to real time, and ensuring that only qualified physicians with relevant expertise review requests that may be denied for medical necessity.
Yet none of these actions delivers full value if only one side modernizes. Prior authorization will fulfill its potential only when plans and providers work together to make the process interoperable, smooth, and reliable. This means hospitals, clinics, and other community providers must not merely embrace compatibility. They must strengthen and manage their systems effectively so they can support care, give members realistic expectations, and submit authorization requests with timeliness and accuracy.
A Statewide Standard
Health plans operate in a highly regulated environment, so lasting change cannot happen without sound policy support at the state level.
Unless data exchange and interoperability requirements are applied to providers, adoption will fall short of being universal. In regions where industry consolidation has left health plans with little bargaining power, provider adoption is critical.
The prior authorization process asks a health plan to tell a family yes or no when they are at their most vulnerable. That’s why public trust falters when prior authorization goes badly, and that’s why it’s worth fixing.
Standardizing prior authorization processes across all plans would bring paperwork, coverage codes, and data exchange frameworks into alignment. Coverage of therapeutic and diagnostic services should produce consistent answers regardless of the health plan. As California prepares to elect a new governor, we have an opportunity to make this important change.
I have five Medicare-eligible uncles. Every year they compare plans, weigh the benefits, and look for the best deal. I would love to know that whichever plans they pick, their coverage will be evaluated and approved by consistent analyses of the evidence. When that happens, providers, payers, and patients will all know that the prime consideration will be their health care needs.
