Will AI Fix Prior Authorization — or Make It Worse?
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If you’re like me, you or a loved one has struggled through the process of gaining pre-approval for the medical care that your physician has recommended. Personal stories abound regarding the tribulations of patients as they go through hoops to get their health insurer to pay for certain prescription medications, medical procedures, and more.
When used judiciously, this process — known as prior authorization — serves as a check on overuse and spending on services or technologies for which there are less costly alternatives. But a large majority of physicians voice concerns about care delays, which can cause patients to abandon recommended treatments while waiting for the insurance company to verify their eligibility and confirm that the treatment is, indeed, medically necessary. Patients who are denied care may submit an appeal, but that requires more time.
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AI might be able to help. With its ability to efficiently sort through vast reams of information, artificial intelligence could theoretically expedite approval of unambiguously allowable claims, thereby reducing care delays. However, AI-driven prior authorization is facing resistance, as it may increase wrongful denials of health insurance coverage. A 2025 American Medical Association survey of physicians revealed significant concern about application of AI tools, with 61 percent of doctors worrying that AI will exacerbate denials of what they deem are necessary treatments.
The AMA advocates requiring insurers to provide detailed clinical reasoning to justify denials of coverage, in addition to more transparency regarding AI algorithms.
In an email to Undark, health policy analyst Camm Epstein wrote that “AI should be used to make appropriate care easier to approve, not necessary care easier to deny.”
President Donald Trump’s administration is currently piloting a program in six states, using AI to reduce unnecessary medical spending. But it remains to be seen whether this new approach will help fix a tortuous system.
Regardless of the degree to which AI is involved, the public views prior authorization as a major burden. In Medicare Advantage — the privately run alternative to original Medicare that now enrolls roughly 55 percent of Medicare-eligible seniors and disabled people — insurers issue millions of full or partial claim denials annually based on prior authorization. Federal government reports issued in June showed that plans sometimes even reject requests for skilled nursing and rehabilitation admissions. Erecting obstacles to medically appropriate care is viewed as a particular area of concern.
Patients can request medical exemptions or appeal plan decisions, but the process is often complicated and cumbersome. NBC News reported that some patients are “stuck in prior authorization” purgatory as they “run out of time or treatment options.”
A newly released Commonwealth Fund survey finds that roughly one in five American working-age adults with private insurance reported that either they or a family member were denied insurance coverage for physician-recommended medical care in 2025. Forty-one percent of people who experienced a prior authorization denial said it delayed their care, and more than a quarter reported that their health problem worsened as a result.
“AI should be used to make appropriate care easier to approve, not necessary care easier to deny.”
The government and private insurers have tried to make improvements.
A rule issued by former President Joe Biden’s administration in 2024, for example, included reforms designed to reduce delays for patients with government-run plans while streamlining the prior authorization process for physicians. It required insurers to make certain prior authorization decisions within 72 hours for urgent requests, and seven calendar days for non-urgent requests. Per Jan. 1 of this year, these timeline requirements went into effect for most health plans in the public sector. Last year, together with insurers, the Trump administration pledged to further streamline and accelerate...