The Prior Auth Machine

Or, How I Learned to Stop Shrugging at the Fax Pile and Read the MGMA Report

It's Saturday morning here in Chandler and I'm finally sitting down with coffee — decaf, these days, part of a longer story — and thinking about a stack of paper that doesn't exist anywhere except in my office's collective memory.

The short version of the longer story: I told some of you back in December about the ascending aortic aneurysm I was diagnosed with after a stretch of thirty-six-hour Covid-surge shifts and roughly twenty cups of coffee a day. The last reading came in at 4.2 cm. No longer aneurysmal. Decaf was part of it. So were the vacations my wife and I started taking, the weight I lost, the stress I let myself unload, and a hundred other small lifestyle decisions that turned out to add up to a longer, happier life. I am writing more, traveling more, sleeping more, and shouting at fewer payers. The shouting reduction may be the most therapeutic of all of those.

A quick note from the writing side, because this is also where I keep the Animulus Forge work. On flights this year — and there have been a number of them — I have finished the final touches on my novel, The Last Doctor, and posted it on the Black List for industry feedback. The screenplay rewrite of A Taste for Lunacy is nearing completion as well. After the festival run last fall, the rewrite has felt different in the best way. I will share more soon. The relevant point for today is that I have done some of my best writing at thirty-six thousand feet, while not on call, while not in front of a fax machine. There is a lesson in that, and it bears on what I want to write about now.

The prior authorization fax pile.

It used to live on a corner of the front desk. Now it lives in three different software portals, two payer-specific web forms, and the inboxes of two staff members whose entire job is to fight payers for permission to give patients medications I have already prescribed. The pile got digitized. It did not get smaller.

I want to walk you through why that’s not a feeling. It’s a number. Several numbers, actually.

On April 9, the Medical Group Management Association released its 2026 Regulatory Burden Report. https://www.mgma.com/federal-policy-resources/april-9-2026-regulatory-burden-report

Ninety-five percent of practice leaders say regulatory burden has increased over the past three years. Seventy-seven percent say that burden is a major contributor to physician burnout. Forty percent of practices now hire multiple full-time administrative staff per physician — not for billing, not for scheduling, but specifically to manage payer rules, audits, appeals, and reporting. Ninety percent of practices say prior authorization got worse in the last year alone. https://www.fiercehealthcare.com/providers/regulatory-burdens-continue-mount-physician-practices

That’s 230 group practices nationwide. About half with twenty or fewer physicians. Sixty percent independent, like mine.

I should say this plainly: I am not a hospital CEO. I run an independent medical-behavioral integrated private practice in Chandler, Arizona, and I serve as Senior Medical Director for Intracare. The practice is still mine. The role at Intracare is broader. I have been in Arizona Family Medicine for twenty-seven years, since 1999, and I have been a physician since May 1996 — coming up on my thirtieth year next month, which still doesn’t seem real to me. So when I tell you the prior auth pile is the worst it has been in my career, I am pulling from thirty years of receipts.

In 1996 I could write a single line on a prescription pad and a patient could go fill it. There were exceptions. There were always specialty drugs and brand-name fights. But a statin? A blood pressure med? A first-line antibiotic? The pen worked.

In 2026 I prescribe a statin and somebody who has never met my patient — usually somebody without an MD or DO after their name — decides whether the patient gets it this week. The MGMA report quotes one of my colleagues directly: “In the last year, I have had to add two new staff dedicated to handle the growing volume of prior authorizations, bringing the team to a total of four working on them full-time. This was the only way to ensure prior authorizations were completed on time and to avoid rescheduling patients, since nearly all of our visits require authorization.” https://www.mgma.com/getkaiasset/8c7263b8-882d-4f6a-8d6c-48180fba72c9/MGMA%202026%20Reg%20Burden%20Report%20.pdf

Four staff. For one physician’s prior auths.

This is the thing I keep wanting my non-medical friends, the screenwriters and the readers of this Substack and the people who ask me at parties what’s wrong with American healthcare, to understand. When you read that physicians are burning out, the picture in your head should not be a tired doctor. The picture should be an entire shadow workforce — paid by the practice, billed nowhere — whose job is to translate clinical decisions into the language of utilization review. Every dollar that pays them is a dollar not paying for patient care. Every minute they spend on a fax appeal is a minute the practice cannot use to see another patient.

That’s what 25% of healthcare spending going to administration actually looks like on the ground. https://www.mgma.com/getkaiasset/8c7263b8-882d-4f6a-8d6c-48180fba72c9/MGMA%202026%20Reg%20Burden%20Report%20.pdf

So.

Some good news, and I do mean it.

The CMS Interoperability and Prior Authorization Final Rule, CMS-0057-F, took effect January 1, 2026. It is the most meaningful federal action on prior auth in my career. It requires impacted payers — Medicare Advantage, Medicaid, CHIP, and ACA exchange plans — to issue standard prior auth decisions within seven calendar days and expedited decisions within seventy-two hours. It requires payers to give specific denial reasons instead of boilerplate. And by March 31, 2026, payers must publicly report prior auth metrics — approval and denial rates, appeals outcomes, average decision times. https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f

The API requirements that would actually let payer and EHR systems talk to each other electronically don’t kick in fully until January 1, 2027. https://www.cms.gov/files/document/cms-0057-f.pdf

But the operational rules are real. They are running right now. And I give CMS credit for them.

Here is the catch, and it is enormous.

CMS-0057-F explicitly excludes drug prior authorizations. The thing I fight about most often — getting a patient their medication — is not covered by the rule. The proposed companion rule that would address drug PA, CMS-0062-P, is currently open for public comment through June 15, 2026. https://www.cms.gov/priorities/burden-reduction/overview/interoperability/policies-regulations/cms-interoperability-standards-prior-authorization-drugs-proposed-rule-cms-0062-p

If you work in healthcare operations, pharma, payer strategy, or policy — submit a comment. Name the downstream cost of drug PA delays. Medication non-adherence. ED visits. Worse outcomes. More hospitalizations. Payers don’t carry those externalities on their balance sheet. We do, and our patients do.

Now the harder catch, the one MGMA flagged in this report and that I had not fully tracked until I read it carefully:

CMS is now expanding prior authorization in the opposite direction. The Wasteful and Inappropriate Service Reduction Model — WISeR — pulls prior auth into Traditional Medicare for certain services, where it had not previously lived. https://www.mgma.com/getkaiasset/8c7263b8-882d-4f6a-8d6c-48180fba72c9/MGMA%202026%20Reg%20Burden%20Report%20.pdf

So on one hand we get faster Medicare Advantage turnaround times. On the other hand we get prior auth introduced into the program that has historically been the cleanest to work with. CMS giveth and CMS taketh away.

The MGMA report’s framing of this is the right one: faster turnaround alone will not alleviate the immense burden. The volume is the problem. Reducing the volume of services that require prior authorization in the first place is the reform that matters.

I have spent twenty-seven years in Arizona Family Medicine. I came up through AIDS care in residency, fought the State on Covid distribution in 2020, ran a Covid surge team while my own aortic aneurysm was quietly growing toward 4.6 cm. I have argued with payers since payers existed. I want to say this clearly so that you can quote me on it if you want:

The single highest-leverage intervention for physician burnout right now is not another mindfulness app, another wellness committee, or another resilience training. It is shrinking the prior auth machine.

That is a policy fight. It belongs to CMS, to Congress, to state insurance commissioners, to the public-comment period on CMS-0062-P that closes June 15. It does not belong on the shoulders of individual doctors who are already drowning.

If you read this and you have a way to weigh in — submit. If you don’t, but you know someone who does — forward this. The MGMA report is a serious piece of work and I want it read by more than the ten thousand of us who already lived through what it describes.

Thirty years next month. The fax pile, in whatever form it takes that week, is still there.

I would like to make some of it go away before year thirty-one. I would also like to finish the rewrite, sell the novel, and get back on a plane. Those goals are connected. They are the same goal. A doctor who can write at thirty-six thousand feet is a doctor who has the room to think, and I want every one of my colleagues to have that room.

— Dr. Andrew Carroll

Chandler, Arizona

April 25, 2026