For those who’ve ever been a affected person ready—days, typically greater than every week—for therapy approval, or a clinician caught chasing it, you understand what prior authorization looks like. Sufferers sit in limbo, anxiousness rising as care stalls. Nurses and physicians commerce hours of affected person time for telephone calls, faxes, and glitchy portals. Everybody waits, some in ache, whereas the folks on either side of the system lose religion in it a bit extra every day.
This isn’t a minor inconvenience. In line with the American Medical Affiliation’s (AMA) 2024 Prior Authorization Doctor Survey, 93% of physicians report that prior authorization delays entry to care, and 94% say it negatively impacts affected person outcomes. Physicians deal with a median of almost 40 requests every week, spending 13 hours of their time on the method. Almost 9 out of 10 share that it’s a contributing issue to burnout.
We’ve been down this highway for a few years. In 2018, well being insurer and supplier teams signed a consensus assertion promising vital enchancment of prior authorization. In 2023, the AMA reported that two main insurers pledged to scale back the variety of companies needing prior authorization.
The guarantees added up—so why hasn’t the burden eased?
Final month, AHIP (a nationwide commerce affiliation representing the medical health insurance trade) and main payers rolled out six reforms standardizing digital submissions, rushing choices, enhancing transparency, and preserving continuity of care when members change plans. Greater than 50 main well being plans, encompassing 257 million People, signed on to be part of this reform with all commitments delivered by 2027. That’s necessary. However for somebody awaiting chemotherapy or a nurse on the ward, 2027 looks like ceaselessly away.
No want to attend
Actual reform doesn’t want to attend. Right here’s what’s already occurring inside well being plans which have embraced agent‑primarily based AI techniques—know-how is being put in place that’s designed not simply to hurry up types however to essentially change how prior authorization and different core operations get achieved. These techniques don’t change folks. They work alongside nurses, case managers, and directors, dealing with the repetitive, document-heavy work so people can deal with medical choices and affected person care.
Tangible outcomes
This AI is simply starting to be adopted by plans; the transformation is measurable:
- Turnaround occasions are slashed by greater than 50%.
- 76% of authorizations are dealt with mechanically.
- Eighteen minutes are saved per prior authorization request, which for an average-sized well being plan unlocks tens of hundreds of hours every month, that allows medical care groups to shift from administrative work to larger deal with sufferers.
- AI can deal with the tedious elements of the method—sorting by PDFs, faxes, and medical notes—in seconds as an alternative of hours, whereas protecting nurses and physicians concerned for the selections that require human judgment.
Paradigm shift
This isn’t only a tweak to the outdated course of—it’s a shift that enables total operations groups to work in a different way. Sufferers get faster solutions and fewer anxious telephone calls. Suppliers get again extra time to spend serving to sufferers. For the folks working behind the scenes, it means shifting previous the repetitive paperwork grind—hours spent sorting by types, faxes, and recordsdata—and specializing in work that really helps higher care.
AHIP’s personal language makes the case: these reforms are supposed to present quicker entry to evidence-based care, simplify workflows for suppliers, and protect care continuity when folks change insurers. That must be the minimal normal—not a distant promise.
Well being plans have to act now—scaling present AI deployments and embracing course of redesign—to allow them to ship three concrete outcomes at the moment:
- Sufferers can begin the therapies they want sooner, with out the fixed again‑and‑forth or lengthy waits for approval.
- Docs and nurses get again worthwhile time, to allow them to spend extra of their day with sufferers as an alternative of buried in types and telephone calls.
- Folks can hold their care shifting, even when they change insurance policy mid‑therapy, with out having to start out the approval course of yet again.
Inside attain
Well being plans don’t want to attend for 2027. The know-how exists at the moment to ship significant prior authorization reform. And let’s be trustworthy: one other spherical of press releases gained’t change outcomes. However scaling the outcomes and influence that AI is delivering to prior authorization at the moment—that’s reform in movement. And it’s inside attain.
For sufferers trapped in limbo and clinicians stretched thinner daily, reform can’t arrive quickly sufficient. The query isn’t whether or not we will make prior authorization quicker, easier, and fewer wanted. It’s when well being plans will act—for the sake of all these concerned in our well being system, we should select urgency.
