Will AI fix prior authorization—or make it worse?

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. 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 prior authorization processes. Private insurance companies vowed to standardize electronic requests by 2027 and to “reduce the volume of medical services subject to prior authorization” by 2026, including for common procedures like colonoscopies and cataract surgeries. Now, the Trump administration wants to further ameliorate prior authorization protocols by expanding the use of AI. Additionally, vendors participating in the WISeR model, who were hired to carry out AI-driven prior authorization, earn a share of what CMS calls “averted expenditures.” This could entail revenues for rejecting care requests. In turn this points to a broader discussion about long-standing concerns regarding profit-making on the basis of discouraging patients from getting medically necessary care. Several lawmakers have introduced resolutions and amendments to block funding for the WISeR model, citing threats to patient access. Yet the Trump administration seems to be of two minds when it comes to prior authorization. As CMS expands its use in original Medicare using AI, the agency wants to lessen and streamline its use by private insurers, including Medicare Advantage plans. CMS Administrator Mehmet Oz has warned insurance company executives that they must ease the burden of prior authorization, or the federal government will impose regulation: “If you don’t do it yourselves, then we’re going to do it for you,” he told the National News Desk, a TV news program. Possibly to preempt further executive branch action or passage of laws by legislators, health plans released data recently that suggest they’re complying with administration demands. The industry-based survey reveals that between June 2025 and April 2026, requests for prior authorization declined by 11 percent. It’s unknown, however, whether the denial rate has decreased. Responding to an industry group survey conducted last year, all responding health plans agreed with the statement, “AI or algorithms without clinician or practitioner review are not used to deny prior authorization requests that involve medical necessity or clinical considerations.” Moreover, insurers promised more transparency around clinical reasoning underlying prior authorization. This may alleviate some of the worry about a lack of human review of decisions made by AI. But placating detractors won’t be easy. Jared Dashevsky, a physician and founder of a media and educational platform called Healthcare Huddle, wrote that AI could “eliminate barriers, reduce administrative waste, give us more time with patients. But that’s not what’s being built.” Instead, he says, there’s an “arms race to deny faster and appeal faster. More automation of a broken system that shouldn’t exist in its current form.” This article was originally published on Undark. Read the original article.