Few phrases increase blood strain amongst medical doctors and sufferers like “prior authorization.” Ask any clinician and also you’ll hear the identical story: delayed remedies, infinite back-and-forth, and susceptible people left ready whereas paperwork wins the day.
For suppliers, prior authorizations are a relentless drain of time and power. For sufferers, they’ll imply worsening circumstances, missed home windows for efficient therapy, and even care that by no means arrives in any respect. And for payers, prior authorizations are a blunt instrument used to manage expenditures and implement documentation—generally creating stress with the very clinicians attempting to ship well timed care.
These challenges have sparked a race towards options that promise pace. Automation and now AI are held up as saviors: fewer clicks, quicker responses, diminished administrative burden. Sure, effectivity issues, however let’s be trustworthy. Quicker prior authorizations received’t occur if the aim of them is to dam, delay, or deny care. There’s a motive prior auths aren’t speedy—the delay could be a ‘function,’ not a bug.
Velocity alone received’t repair the issue. The truth is, dashing a damaged course of may even make issues worse.
Prior Auth Isn’t a Velocity Downside—It’s a Methods Downside
Keystrokes aren’t the actual supply of delay. The core concern is competing incentives. Clinicians gauge success by how rapidly and safely they’ll begin therapy, whereas payers measure it by how successfully they’ll include prices and implement compliance.
These goals collide each day, leaving physicians within the exhausting place of chasing approvals whereas attempting to maintain sufferers entrance and middle. The result’s predictable: friction, mistrust, and sufferers ready in limbo.
This dilemma has fueled a rush towards expertise, with guarantees to chop handbook entry, course of requests quicker, and get approvals transferring. However right here’s the entice: including extra quantity and quicker processing to an already misaligned system doesn’t make it higher. It magnifies the dysfunction. If the underlying workflows stay misaligned, scaling simply compounds the unsuitable outcomes.
And whereas expertise can actually assist, we should be sensible in regards to the nature of the issue. Healthcare at giant lacks each technical interoperability and enterprise interoperability, whereas the incentives of payers and suppliers stay basically misaligned.
Till each are addressed, new instruments will at greatest nibble on the edges and at worst add gas to the hearth.
Why Automation Alone Can Make Issues Worse
The enchantment of accelerating prior authorizations with expertise is clear. On common, they eat 12 hours of employees time each week, so automating approvals or denials appears like a aid. Bots can click on the correct fields, auto-fill varieties, and transfer requests by means of the queue quicker than a human ever may. On the floor, this seems like progress.
However drop AI into the realm of misaligned incentives, and what occurs? You would possibly get quicker denials. Extra duplicate requests. Even much less time for clinicians to concentrate on precise affected person care, as groups are compelled to chase down exceptions, resubmit documentation, or enchantment selections that by no means ought to have been denied within the first place. What seems like “effectivity” on paper can, in observe, push extra administrative burden again onto the identical suppliers already stretched skinny.
For sufferers, the impact is harmful. Quicker denials can imply longer waits, extra uncertainty, and higher threat of circumstances worsening whereas the system kinds itself out. In different phrases, expertise utilized with out fixing systemic gaps doesn’t take away friction, however multiplies it.
Think about paving a six-lane freeway between two cities with out agreeing on which facet of the street to drive on. You’ll transfer vehicles quicker at a higher threat of accelerating accident charges.
That’s why automation can’t be the endgame. To construct one thing higher, we have now to step again from the instruments themselves and take a look at the inspiration: how folks, processes, and expertise match collectively. With out that alignment, no quantity of pace will transfer care ahead.
Individuals, Processes, and Tech—In That Order
The method of prior authorizations received’t be improved with shinier instruments alone. The healthcare ecosystem should rethink its order of operations: folks, processes, then expertise. Too typically, the business begins with tech and hopes the remaining will observe. That’s why the identical frustrations preserve resurfacing.
- Individuals. Sufferers, suppliers, and payers all want visibility and accountability. Belief can solely be solid when everybody sees the identical guidelines utilized constantly, no matter which facet they’re on. With out that basis, each prior authorization appears like a negotiation as an alternative of a regular.
- Processes. Workflows should be redesigned to reward collaboration, not competitors. If either side remains to be defending its personal pursuits, then automation merely accelerates conflicts. When processes are structured round shared outcomes—like well timed entry to high quality care—disputes shrink and belief grows.
- Expertise. Solely after folks and processes are aligned does expertise create actual worth. That’s after we transfer past bots that push paper and create actual partnerships that assist clinicians, flag true exceptions, and eradicate the work nobody ought to be doing within the first place.
The Function of AI—When It Helps
AI has promise, however solely when utilized to aligned workflows. Used within the unsuitable context, it simply reinforces silos and accelerates the unsuitable work. For instance, if two departments unknowingly submit the identical request, automation can push each by means of the system with out query, clogging the method as an alternative of fixing it.
Used appropriately, although, AI enhances trust-based programs. It may well flag these very duplicates earlier than they waste time, spotlight true exceptions that want human evaluation, and streamline routine approvals everybody already agrees on.
When expertise is utilized appropriately to an aligned system, authorization selections change into steadier, extra clear, and much simpler for sufferers and suppliers to depend on.
Prior Authorization as a Warning Gentle
Like a warning mild on a dashboard, prior authorization indicators a deeper systemic downside. Prior authorization typically will get the highlight, however the actual concern runs deeper. The identical inefficiencies that maintain up approvals additionally gradual referrals, delay discharges, and complicate transitions of care.
For instance, a doctor could lastly safe an approval solely to face a brand new set of boundaries in transferring a affected person to the correct facility. A post-acute supplier could settle for the referral, solely to find the documentation hasn’t been adopted. Every step turns into one other ready room.
Taking a look at prior authorization by itself narrows the issue an excessive amount of. The larger alternative is aligning incentives throughout the complete continuum of care. When payers, suppliers, and post-acute companions share accountability, authorizations transfer quicker. Extra importantly, sufferers proceed by means of the system with fewer setbacks at each stage.
In our work with main well being programs, care managers have a greater steadiness of management of the prior authorization course of with post-acute suppliers, gaining new visibility into the place requests stand. With clearer perception into denial charges and turnaround occasions, they’re not solely defending sufferers from pointless delays but additionally equipping themselves with the info wanted to strengthen payer contracting conversations.
Classes for Well being Tech Leaders and the Path Ahead
In case you’re constructing options in healthcare, right here’s the takeaway: don’t bolt intelligent instruments onto damaged workflows. Align incentives. Construct governance into the system. Create constructions the place collaboration is rewarded. Return to first rules.
Velocity is sweet. However equity, transparency, and accountability are non-negotiable. And what’s proper shouldn’t be sacrificed for what’s quick.
Bots received’t repair prior authorizations. We want a greater system—one constructed on trusted, rules-based relationships the place all sides share duty for getting sufferers the correct care, on the proper time, each time.
About Russell Graney
Russell Graney is the Founder and CEO of Aidin, a platform devoted to simplifying care administration and enhancing care transitions. He started his profession at Bain & Firm, advising Fortune 50 corporations, and later co-founded a constitution faculty in Brooklyn that now serves over 600 college students yearly. Motivated by his uncle’s prognosis of early-onset Alzheimer’s, Russell left personal fairness to create Aidin.
