Joseph Mathews knew how the system worked. He runs an orthopedic practice. He understood Medicare Advantage, referrals and prior authorization. When his mother broke her hand, he knew which calls to make and how to push for care.
She still waited more than a week to reach the appropriate specialist. Because she was enrolled in a Medicare Advantage HMO, the emergency department visit was only the beginning. She first had to see her primary care physician, obtain a referral and move through the plan’s approval process.
“This was my own mother,” Mr. Mathews, CEO of Houston-based Advanced Orthopaedics and Sports Medicine, a division of OrthoLoneStar, told Becker’s. “She had a son in the medical industry helping her, and we still struggled for more than a week.”
The fracture was visible. The obstacle was administrative. For older patients without a healthcare executive in the family, the same process can be harder to challenge. Some wait. Some deteriorate. Some give up.
That is the problem the Improving Seniors’ Timely Access to Care Act is intended to address. The bipartisan legislation would not eliminate prior authorization in Medicare Advantage, but it would standardize electronic processes, establish clearer decision timelines and require plans to disclose more information about approvals, denials and the use of automated tools.
For Mr. Mathews, who is also on the board and advocacy council of the American Alliance of Orthopaedic Executives, the legislation confronts something larger than inefficient paperwork. Prior authorization now determines when orthopedic patients receive care, how practices schedule surgery, whom they must hire and whether independent groups can afford to remain independent.
“Prior authorization has become the single biggest obstacle between a senior and the care they’ve already earned through a lifetime of paying into Medicare,” he said.
A toll gate in front of orthopedic care
Orthopedics is particularly exposed to prior authorization because so much of the specialty sits behind it. An evaluation may lead to an MRI. The imaging may lead to physical therapy, an injection, a joint replacement or spine surgery. Each step can trigger another request, another portal and another opportunity for delay.
The physician determines what the patient needs. The practice then has to prove it to the insurer.
“Prior authorization is consistently ranked among the top administrative burdens physicians face, especially in orthopedics,” Mr. Mathews said. “So much of what we do sits behind a prior authorization gate before the patient gets treated.”
The 2025 American Medical Association Prior Authorization Physician Survey found practices complete an average of 40 authorizations per physician each week, consuming about 13 hours of physician and staff time. Ninety-five percent of surveyed physicians said prior authorization delays necessary care. Seventy-nine percent said patients have abandoned treatment because of authorization challenges. More than 1 in 4 said the process had contributed to a serious adverse event, including hospitalization, permanent impairment or death.
“My staff did not go into healthcare to spend their afternoons on hold with insurance companies,” Mr. Mathews said.
Plans argue that prior authorization helps prevent unnecessary or excessively costly care. The harder question is whether the current system efficiently reaches the right clinical decision, or makes obtaining that decision so burdensome that some patients and practices stop trying.
The denial that anticipates surrender
An initial denial is not always an insurer’s final answer. Sometimes, it is the opening position.
A 2018 HHS Office of Inspector General review found Medicare Advantage organizations overturned about 75% of their own denied prior authorization and payment requests when patients or providers appealed. Yet only a small share of denials were appealed. The findings expose the system’s central imbalance. Persistence can work, but many patients do not have the time, knowledge or stamina to persist.
“When 3 out of 4 denials get overturned on appeal anyway, that’s not utilization management,” Mr. Mathews said. “That’s just friction.”
In healthcare, friction can become a clinical event. A patient in pain may decide another round of therapy is not worth the fight. An older adult may stop calling after hours in a phone tree. A surgeon may postpone an operation while the patient’s function declines. The insurer may eventually reverse the decision. The patient does not get the waiting period back.
Mr. Mathews had confronted the problem again just hours before his interview with Becker’s. An older patient who used a walker wanted additional physical therapy, but his plan would not authorize it. The patient blamed the practice.
“I told him, ‘That’s your plan. I cannot do anything,’” Mr. Mathews said. “I can request it. I can appeal it. I can do peer-to-peer. Then, when they say no, it has to be self-pay.”
Patients often experience prior authorization not as a dispute between a provider and an insurer, but as their physician refusing care. The practice absorbs the anger for a decision it did not make.
The wait is built into the schedule
The burden is not only clinical. It changes the operating model of an orthopedic practice. When one insurer began requiring prior authorization for physical therapy provided to Medicare Advantage patients, Mr. Mathews’ group had to hire another full-time employee to manage the requests.
The patients did not change. The therapy did not change. The reimbursement did not increase.
“Nothing changed,” he said. “We were treating the same patients for the same reimbursement, but now there was an additional cost.” The expense appears in salaries, turnover and staff hours spent moving between fax machines, automated phone systems and proprietary portals.
Practices send records. Insurers say they were not received. Staff members transmit them again. Surgery scheduling has also changed. Mr. Mathews’ team has found that certain plans can take close to two weeks to authorize an operation. The practice has adapted by avoiding elective scheduling inside that window.
“Unless it’s an emergency, don’t even put the patient on the schedule for the next 14 days,” he said. “We need the time to chase it.”
Scheduling a case sooner risks reaching the operative date without approval. If the case has to be moved, the practice may have to restart the authorization. The delay is no longer an occasional malfunction. It has been built into the calendar. A surgeon may be available. The patient may be ready. The operating room may be open. The insurer’s timeline becomes the controlling resource.
A peer review without a peer
After a denial, physicians may be offered a peer-to-peer review. The term suggests a discussion between clinicians with comparable expertise who have carefully reviewed the patient’s record.
That is not always what physicians encounter. Mr. Mathews recalled listening as a spine surgeon was asked why a patient needed surgery. The surgeon first wanted to know whether the insurer’s reviewer had read the clinical notes. The reviewer had not.
In another case, the reviewing physician did not specialize in spine care. The surgeon asked when the reviewer had last performed spine surgery. The silence answered the question.
“How would you understand when I tell you why this patient needs surgery?” Mr. Mathews recalled the surgeon asking. The AMA survey found only about one-quarter of physicians participating in peer-to-peer reviews said the plan’s reviewer often or always had appropriate qualifications. The conversation may satisfy an insurer’s procedural requirement. That does not make the reviewers peers.
AI widens the imbalance
The stakes are growing as insurers use automated tools to process authorization requests. Technology could make prior authorization faster and more consistent. But it can also deepen the imbalance between the organization generating denials and the practice contesting them.
A machine can review or flag thousands of claims. A practice still has to appeal each decision with human labor. Every challenge requires staff time. A peer-to-peer removes a physician from patient care. A resubmission may require another chart review, call and round of documentation.
“If there is an automatic denial through AI, it doesn’t cost them as much as it costs us,” Mr. Mathews said. “They’re drowning us out.”
Without disclosure, a physician may not know whether a human reviewed the record, which criteria determined the outcome or what evidence could change it. For Mr. Mathews, transparency around automated tools is therefore not a technical detail. It determines whether patients and physicians can understand who, or what, influenced a coverage decision.
“The transparency requirements will force plans to publicly report approvals, denials and the reasons,” he said. “That is necessary for providers and patients.”
The burden favors scale
For a national health system or large physician platform, prior authorization can be managed through centralized teams and technology. For an independent group, every new requirement lands directly on the operating margin. The practice hires another employee. The surgeon spends another hour on a peer-to-peer. The billing team learns another portal.
At the same time, labor and supply costs rise while physician reimbursement remains under pressure. Eventually, independence becomes harder to sustain.
“It is not a surprise that the majority of physicians in this country are now hospital-owned or private equity-owned,” Mr. Mathews said. “Independent practices cannot continue to take these hits, increased costs and increased regulatory burdens while they are getting paid less.”
Prior authorization is rarely described as a consolidation force. But the process rewards scale. A large organization can spread its administrative costs across thousands of clinicians. A smaller practice may have to stop accepting a plan, move toward cash-pay services or sell.
A system designed to control healthcare spending may therefore weaken independent practices that can often deliver care in lower-cost settings.
Health insurers have made voluntary commitments to reduce prior authorization requirements, improve electronic processes and increase transparency. Mr. Mathews said practices have heard similar promises before. He has not felt meaningful relief. That is why he sees binding legislation differently from another industry pledge.
“The transparency is the real win,” he said. “Once plans have to publish their numbers on approvals, denials and the reasons for the denials, the incentive to slow-walk approval starts to disappear.”
Public reporting would allow patients, employers, physicians and regulators to compare plans based on more than premiums and provider networks. A plan may look different when its denial rate, average decision time and appeal outcomes become visible.
Transparency would not guarantee approval. It would make delay measurable. And what can be measured becomes harder to hide.
Congress already knows what is wrong
The Seniors’ Timely Access legislation has received broad bipartisan support and has been introduced before without becoming law. The problem is not a lack of evidence. Lawmakers have the physician surveys, government audits and patient stories. A previous version cleared the House before stalling in the Senate over its projected cost.
For Mr. Mathews, orthopedic leaders cannot treat the legislation as someone else’s fight. Physicians, therapists and practice administrators need to tell lawmakers what prior authorization looks like on the ground: the employee hired solely to chase approvals, the surgical slot left unused, the physician reviewing a case outside their specialty and the patient who believes their doctor is withholding treatment.
Those stories reveal what administrative data cannot. Time is not an abstraction for a patient who cannot walk, use a hand or return to work. It is part of the outcome.
“At the end of the day, this bill is about one thing,” Mr. Mathews said. “It is making sure that a senior’s diagnosis, and not the insurance paperwork, decides how fast they get treated.”
A denial can be appealed. A decision can be reversed. Medicine has no process for returning the days a patient spent waiting.
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