Worcester Business Journal

wbjournal.com | April 20, 2026 | Worcester Business Journal 15 HEALTH CARE F O C U S operating loss between fiscals 2020 and 2024, according to the Center for Health Information and Analysis. Gardner-based Heywood Health- care has staff working on prior au- thorizations at all of its 15 healthcare sites, including hospitals, primary care facilities, and urgent care centers, said John Bujak, the system's CFO. Not only will reform alleviate cost burdens, but it will return a certain amount of trust to doctors who feel handcuffed to the bureaucratic mea- sures of health insurers, said Bujak. e American Medical Associ- ation found 95% of U.S. physicians say prior authorizations somewhat or significantly increase their experience of burnout as they average 43 prior authorizations per week. "ey've been trained. ey've got the experience. ey know what they're doing," Bujak said. "It would be wise to entrust in them that the right thing is being done for the pa- tient at the end of the day." Ambulatory services face the highest rates of required prior au- thorization at UMass Memorial and Heywood. Primary care and imaging services, such as ultrasounds and MRIs, are heavily impacted by prior authorization. Imaging prior authori- zations can be so difficult to obtain in outpatient settings that some doctors delay discharging medically ready patients out of concern they won't receive needed care, Dickson said. Eliminating unnecessary procedures e prior authorization system inherently saves patients money on premiums, said Rao from BCBS. BCBS' prior authorizations are estimated to save patients nearly $5 billion in out-of-pocket costs over 10 years, by cutting down on unneces- sary health care, she said. In 2023, a study commissioned by Blue Cross Blue Shield Association from Seat- tle-based consulting firm Milliman concluded U.S. insurees would expe- rience an annual premium increase between $43 billion and $63 billion because insurers would be forced to pay for more services if prior authori- zations went away. Prior authorizations are import- ant for services with the potential to be over-utilized or misused, such as radiology, surgeries, and prescrip- tion drugs, said Rao. Still, in order to reduce the administrative burden, BCBSM in January 2024 removed 14,000 required prior authorizations for commercial members, cutting an additional 13,000 authorizations that September. A member of Healey's Health Care Affordability Working Group, BCBSM does not require prior authorizations for 98% of its claims, she said. All of its plans are accountable to strict turnaround time requirements. "We currently exceed those expec- tations in most cases. Approximately 85% of our decisions are reached within seven days, and our turn- around time for urgent cases is one to two days, including approvals for post-acute care," Rao wrote. ose decisions, particularly denials, lead to additional costs for healthcare providers, said Dickson. At UMass Memorial, about 20% to 25% of commercially insured claims get denied. Heywood has an entire team dedicated to working on issues such as denied claims, prior authorizations, and issues of medical necessity, estimated to cost the system between $200,000 and $300,000 a year. e turnaround time from when Heywood sends bills to insurers to when they're paid is between 30 and 40 days. During this time, the system is footing the bill for patients' care, said Bujak. If that claim is then de- nied, it's an additional 30 to 40 days to work through the appeal process. "All the costs associated with that would go away if we didn't have the denial to start," said Bujak. Hope in reform e elimination of prior authoriza- tions for primary care will significant- ly impact Federally Qualified Health Centers, community-based facilities providing care regardless of an individual's ability to pay, said Steve Kerrigan, president and CEO of Worces- ter-based Edward M. Kennedy Community Health Center. "It's a game changer for us as a health center, and I would be willing to bet for health centers in general," he said. e elimination would immediately impact the health center's adminis- trative processes, allowing physicians to provide more care through more patient visits. "ose are billable visits, and help us not just care for our patients, but also bring in the revenue related to that," said Kerrigan. Prior authorization impact Nearly half of physicians who participated in a American Medical Association's 2024 sur- vey reported prior authorizations often or always lead to increased healthcare resource use, including additional office visits, emergency room visits, and hospitalizations. How often prior authorizations lead to increased resource use Percentage Always 7% Often 40% Sometimes 41% Rarely 9% Don't know 2% Never 1% Source: American Medical Association Steve Kerrigan, CEO and president of Kennedy Community Health Center "It would be wise to entrust in {physicians} that the right thing is being done for the patient." - John Bujak W

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