Red Light. Green Light. Repeat.

Time for a little nostalgia. Remember childhood games that required nothing more than a group of kids and a few simple rules?

In Red Light, Green Light, everyone moved on “green light” and froze on “red light.” Move at the wrong time, and you went back to the starting line.

In Simon Says, you did exactly what Simon said. In Mother, May I?, you moved forward only after asking permission.

For children, these games were fun. In healthcare, the similarities to the prior authorization (PA) process are less amusing.

It Wasn’t Always This Complicated
Prior authorization traces its roots to utilization review programs of the 1960s. By the early 1960s, more than 60 Blue Cross plans reported reviewing hospital admissions for appropriateness, while more than 50 reviewed length of stay.

The idea was straightforward: Healthcare resources are limited, so there should be a way to determine whether inpatient hospitalization was medically necessary. When Medicare and Medicaid were established in 1965, utilization review became part of broader efforts to promote appropriate use of healthcare services.

These early reviews introduced a significant new idea: payers could require approval before care was provided. Prior authorization was born.

Initially, the process was relatively manageable, focusing primarily on hospital admissions and length of stay. A physician could explain a patient’s situation directly to a medical director, and a decision could often be made quickly.

The Game Got Bigger — and More Complicated
As healthcare costs rose and new treatments emerged, prior authorization expanded beyond hospital stays to advanced imaging, outpatient procedures, brand-name drugs and other services. Volume grew — and bureaucracy followed.

Payers developed their own systems, while providers hired prior authorization staff and navigated the requirements of multiple health plans. Technology was supposed to simplify the process, yet healthcare increasingly relied on disparate payer portals, phone calls and faxes.

Even as healthcare became digital, prior authorization remained stubbornly manual. The 2009 HITECH Act accelerated the adoption of electronic health records, transforming how doctors documented and shared patient information. Yet prior authorization often remained stuck in a patchwork of portals, phone calls and faxes.

Federal efforts are now attempting to change that. CMS’s 2024 Interoperability and Prior Authorization final rule requires certain health plans to implement standardized electronic prior authorization processes, with many of the API requirements taking effect January 1, 2027. The rule also establishes faster response requirements — 72 hours for expedited requests and seven calendar days for standard requests.

But for now, the maze remains.

Waiting at the Red Light
The American Medical Association’s 2025 physician survey found that physicians complete an average of 40 prior authorization requests each week, consuming about 13 hours of physician and staff time. Ninety-five percent said prior authorization delays necessary care, while 79% reported that patients abandon treatment because of authorization challenges.

Patients feel the burden, too. A February 2026 KFF poll found that 69% of insured adults considered prior authorization at least somewhat of a burden when getting healthcare — more burdensome than understanding medical bills or getting an appointment.

Which Game?
Which childhood game best describes today’s PA process?

Maybe Red Light, Green Light.
A doctor orders a CT scan. The patient schedules an appointment at the imaging center — and then: Red light. Prior authorization is required. The doctor’s office believes the imaging center should submit the request to the insurance company. The imaging center says it’s the doctor’s responsibility.
Meanwhile, the patient is left waiting.

Or perhaps Simon Says.
Simon says submit the form. Simon says provide more clinical notes. Simon says try another medication first. Simon says… denied.

And sometimes it feels like Mother, May I?
Mother, may I order this test? Mother, may I prescribe this medication? Mother, may I continue a treatment that is working?

Maybe the answer is to stop making healthcare feel like a game.

Prior authorization may be an important place to start. But it is only one symptom of a much larger problem: a healthcare system that has become so complicated that even the people who work in it struggle to navigate it.

We don’t just need to fix the red lights. We need to fix the roads.

The goal should be a healthcare system that makes getting the right care easier — not another obstacle patients and providers have to overcome.

Happy reading,
Suzanne Daniels, Ph.D.