April 27, 2026

Prior Authorization & Health with Dr. Archelle Georgiou

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Show Notes

Stan, Clarence, Barry, and the Health Chatter team chat with Dr. Archelle Georgiou, physician, healthcare executive, and nationally recognized health media expert, about prior authorizations, patient advocacy, and navigating today’s complex healthcare system.

Dr. Georgiou brings more than three decades of experience spanning clinical medicine, managed care, healthcare innovation, executive leadership, and public health communication. With senior leadership roles at major healthcare organizations, extensive board service, and over 2,000 health media segments translating medical complexity for the public, she offers a uniquely comprehensive perspective on how patients can better understand healthcare systems, make informed medical decisions, and advocate for the care they need. Her work as a physician, author, media expert, and healthcare strategist has made her a leading voice in empowering individuals to take control of their health journeys.

Learn more about Dr. Georgiou's great work here.

Join the conversation at healthchatterpodcast.com

Brought to you in support of Hue-MAN, who is Creating Healthy Communities through Innovative Partnerships.

More about their work can be found at https://www.huemanpartnershipalliance.org/

Research

Prior authorization - Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs.

Why do health plans require prior authorization?

Prior authorization is a check that your plan covers the proposed care. It’s also a way the health plan can decide if the care is medically necessary, safe, and cost effective.

What is medically necessary?

A medically necessary service or prescription drug is one that’s needed to diagnose or treat an illness, injury, condition, disease, or its symptoms. It must meet accepted standards of medicine
To decide what’s medically necessary, your health plan must follow any state and federal laws that apply

How do health plans decide what’s safe?

To be considered safe, procedures, treatments, and prescription drugs must meet the latest clinical standards and guidelines.
They must avoid negative interactions between any drugs you’re already taking or treatments you’re receiving.

What medications and services require prior authorization?

Your health plan has a list of medications and services that typically require prior authorization.

Challenges w/ prior authorization

The process of obtaining prior authorization from insurers has become the most burdensome noncost barrier for insured adults trying to access care, according to a new KFF Health Tracking Poll

The analysis highlights that the prior authorization process often results not just in paperwork hassles but also in delays or denials of care.
Roughly two-thirds of adults describe delays and denials by health insurance companies as a major problem, while an additional 24% see them as a minor problem.
In the past 2 years, nearly half (47%) of insured adults report having a health service, treatment, or medication either delayed or denied by their insurer.
That share climbs to 57% among those with chronic conditions.
The KFF analysis highlighted that insurers in Medicare Advantage plans processed nearly 53 million prior authorization decisions in 2024, illustrating the sheer volume of these requirements in practice.

More than one-quarter of the physicians the AMA (AMA survey of 1,000 physicians in late 2024) surveyed reported that prior authorization has led to a serious adverse event for a patient in their care. These shares of surveyed physicians reported that prior authorization led to:

A patient’s hospitalization—23%.
A life-threatening event or one that required intervention to prevent permanent impairment or damage—18%.
A patient’s disability or permanent bodily damage, congenital anomaly or birth defect, or death— 8%.

Gold card - Gold carding is a type of prior authorization reform that requires plans to exempt providers with high prior authorization approval rates.

Advantages:

Reduced Administrative Burden
Faster Patient Care
Improved Provider Satisfaction
Encouragement for High Performance

Disadvantages

Administrative and Implementation Challenges
Potential for Increased Costs
Variability in Quality of Care
Resistance from Insurers

Current Gold Card Programs

Vermont's Gold Carding program - which uses a tiered approach to Gold Carding, was legislatively passed in 2020 and requires each insurer to implement a PA pilot program and report the results to various House committees and the local society for primary care physicians

The 3 tiers correspond to the amount of information required to get a PA approved and whether the PA approval can be automated.

Texas “Gold Card bill” - passed in 2022 enabled physicians who had a PA approval rate of 90% or more, exempt from future PA for a minimum of 6 months on certain services.

Providers do not have to apply to a gold carding program. Instead, health plans assess their data to determine whether a provider meets the 90% threshold.