Healthcare professionals and patients alike express frustration with the term “prior authorization.” Delayed treatments and complex paperwork often leave vulnerable individuals waiting for care that may never come. For providers, these processes consume valuable time and resources, while payers use prior authorizations to manage costs. As the industry seeks solutions, some are turning to automation and artificial intelligence (AI) in hopes of expediting these approvals. But simply speeding up the process may not address the root issues plaguing the healthcare system.
The primary challenge lies not in the speed of approvals but in the competing incentives between clinicians and payers. Clinicians aim to initiate treatment as quickly and safely as possible, while payers focus on containing costs and ensuring compliance. This conflict creates a frustrating dynamic, where providers chase approvals, leaving patients in limbo. Finding a solution requires a closer examination of the entire system rather than merely attempting to enhance speed.
Understanding the Core Issues Behind Prior Authorizations
The inefficiencies associated with prior authorization processes stem from misaligned incentives within the healthcare ecosystem. As healthcare technology advances, the introduction of automation and AI can appear promising, potentially reducing the twelve hours of administrative work that prior authorizations typically demand each week. Yet, increasing processing speed without resolving systemic misalignments may exacerbate existing problems.
AI, when applied without addressing these gaps, can lead to quicker denials and an influx of duplicate requests. Clinicians may find themselves overwhelmed with additional administrative burdens as they navigate the complexities of resubmitting documentation or appealing decisions that should not have been denied in the first place.
The dangers of this approach are evident. Quicker denials can lead to longer waits and increased uncertainty for patients. In a scenario where technology is implemented without a focus on improving underlying workflows, the system risks multiplying existing friction rather than alleviating it.
Rethinking Prior Authorization Processes
To address the challenges of prior authorization effectively, stakeholders must prioritize alignment among people, processes, and technology. First, it is essential to foster transparency and accountability among patients, providers, and payers. Establishing a shared understanding of the rules governing prior authorizations can help mitigate the sense of negotiation that often arises from conflicting interests.
Next, processes should be redesigned to promote collaboration rather than competition. By focusing on shared outcomes—such as timely access to quality care—healthcare organizations can gradually reduce disputes and build trust among stakeholders.
Finally, technology should be introduced only after ensuring that people and processes are aligned. When technology is integrated into a cohesive system, it can enhance trust and streamline approval processes. Rather than merely serving as a tool for speeding up workflows, technology can facilitate meaningful partnerships between clinicians and payers, ultimately benefiting patients.
AI has the potential to play a significant role in this realignment when used correctly. It can identify duplicate requests before they complicate the system, highlight exceptions that require human review, and facilitate routine approvals that all parties agree upon.
Prior authorization should serve as an indicator of deeper systemic issues, rather than being viewed in isolation. The inefficiencies that hinder approvals often also impact referrals, discharges, and transitions of care. For instance, a physician may secure an approval only to encounter additional barriers when transferring a patient to the appropriate facility.
Collaboration across the entire continuum of care is critical. When payers, providers, and post-acute partners share accountability, prior authorizations can move swiftly, ensuring patients receive timely care without unnecessary setbacks.
For healthcare technology leaders, the lesson is clear: avoid placing advanced tools onto broken workflows. Align incentives, embed governance structures, and reward collaboration. While speed is desirable, it should never come at the cost of fairness, transparency, and accountability. A holistic approach will be necessary to create a system that ensures patients receive the right care promptly and consistently.
By addressing these systemic challenges, the healthcare industry can move towards a more effective, efficient, and patient-centered approach to prior authorizations. The focus should remain on building trusted, rules-based relationships where all parties share responsibility for delivering high-quality care.
Russell Graney, Founder and CEO of Aidin, emphasizes the need for fundamental changes in how prior authorizations are handled. With a background in advising major corporations and founding educational initiatives, Graney is driven by personal experiences, including his uncle’s battle with early-onset Alzheimer’s, to improve care transitions and management in healthcare.
