Prior Authorization Reform Starts With Better Data and Automation

Prior authorization has become one of the rare healthcare policy issues that unites physicians, health systems, insurers, employers and lawmakers around a common conclusion: The current process creates unnecessary friction for everyone involved. While prior authorization remains an important utilization management tool, growing evidence suggests that excessive administrative complexity delays care, contributes to clinician burnout and increases costs throughout the healthcare system.

According to the American Medical Association’s 2024 physician survey, physicians complete an average of 43 prior authorizations each week, while 95% report the process contributes to physician burnout and 78% say patients sometimes abandon recommended treatment because of authorization delays.

Yet technology alone will not solve the problem. Members of the Senior Executive Healthcare Think Tank bring expertise spanning healthcare operations, technology, AI, interoperability, workforce strategy and patient experience. Collectively, they argue that meaningful reform requires more than faster approvals—it requires redesigning how prior authorization works altogether.

The perspectives that follow explore where healthcare leaders believe reform efforts should focus first—from reducing unnecessary reviews and increasing transparency to advancing interoperability, automation and shared accountability across the healthcare ecosystem.

“Automating low-acuity, high-approval requests eliminates the majority of the burden without touching clinical integrity.”

– Kat Marie Alvarez, Founder and CEO of Katalyst & Co.

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Eliminate the Work That Adds No Clinical Value

Kat Marie Alvarez, Founder and CEO of Katalyst & Co., argues that organizations often focus on accelerating prior authorization instead of questioning whether many authorizations should exist in the first place.

“Prior authorization fails at the workflow level,” Alvarez says. “The criteria exist. The clinical evidence exists. What breaks is the infrastructure connecting them.”

Rather than redesigning every authorization workflow, she believes healthcare organizations should aggressively automate requests that are consistently approved.

“Automating low-acuity, high-approval requests eliminates the majority of the burden without touching clinical integrity.”

Her argument mirrors a growing policy conversation around reducing administrative work rather than simply digitizing it. Centers for Medicare & Medicaid Services’ new interoperability rule encourages electronic prior authorization while requiring faster payer responses, recognizing that reducing friction requires both workflow redesign and better information exchange.

Alvarez also argues that technology cannot overcome misaligned incentives.

“The real barrier is misaligned incentives,” she says. “Reform closes that gap only when payers and providers are accountable to the same outcome: care delivered on time, at the right cost.”

She points out that the most innovative organizations are already moving ahead voluntarily.

“The organizations leading this are not waiting for mandates,” she says. “They are rebuilding the touchpoints now.”

Standardization Must Come Before Automation

Asaad Hakeem of SARC MedIQ Inc. believes the industry already understands many of the necessary reforms.

“Standardize payer rules, automate approvals for evidence-based care, expand provider gold-carding with guidelines and require real-time decisions.”

Taken together, these reforms would dramatically reduce the variation that currently forces providers to navigate different documentation requirements for each insurer.

However, Hakeem identifies four barriers that continue to slow progress.

“The biggest barriers are payer variability, outdated systems, lack of interoperability and financial incentives tied to utilization control.”

Stop Reviewing Services That Almost Always Get Approved

Harikrishnan Muthukrishnan, Principal IT Developer at BCBS Florida, approaches the issue from decades of enterprise technology modernization experience spanning healthcare and multiple industries. He believes prior authorization reform has focused too heavily on processing speed rather than asking whether certain reviews remain necessary.

“The two most overdue fixes aren’t about speed; they’re about scope and visibility.”

If a service receives approval nearly every time, Muthukrishnan argues, requiring prior authorization simply shifts administrative costs onto providers and patients.

“Stop reviewing things that don’t need reviewing,” he says. “If a service is approved 95% of the time, prior authorization is just a tax on the 95% to catch the 5%, and that math rarely helps the patient.”

His second recommendation centers on transparency.

“You can’t fix what no one can see,” he says. “Criteria are proprietary and shifting, denials say little more than ‘not medically necessary’ and there’s no scorecard to compare payers.”

Public reporting could fundamentally change those dynamics.

“Once approval rates by service are public, the obviously removable categories name themselves, and the black box stops being something providers fight and starts being something they can actually engage with.”

“True progress means a clinician should instantly know a payer’s specific documentation criteria at the point of care.”

– Mahendran Chinnaiah, Digital Healthcare Architect at a major U.S. healthcare and pharmacy services firm

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Interoperability Should Make Prior Authorization Nearly Invisible

Mahendran Chinnaiah, Digital Healthcare Architect at a major U.S. healthcare and pharmacy services firm, believes the industry’s greatest opportunity lies in embedding electronic prior authorization directly into clinician workflows.

“The single most impactful practical change is establishing an interoperable Electronic Prior Authorization (ePA) workflow built directly into EHRs using open standards such as HL7 FHIR APIs.”

Instead of requiring physicians to leave clinical workflows or submit manual documentation, he envisions prior authorization becoming almost invisible.

“True progress means a clinician should instantly know a payer’s specific documentation criteria at the point of care, eliminating manual data entry and antiquated faxing.”

However, he says two obstacles continue to limit adoption.

“The first is the data standardization gap,” he says. “While major payers are aligning data submission requirements, the actual clinical notes within EHRs remain heavily unstructured, breaking automated rules engines.”

The second obstacle, he says, is “proprietary ecosystem resistance.” Legacy vendors frequently impose costly integration requirements that discourage open interoperability.

“These financial barriers delay the real-time responses patients desperately need.”

Electronic Prior Authorization Is Already Technically Possible

Jason Foodman, Managing Director at Archetype Growth, approaches prior authorization from the perspective of a technology entrepreneur who has spent decades building healthcare platforms. In his view, the industry has already solved many of the technical challenges. The remaining obstacles are organizational and regulatory rather than technological.

“This is not a problem with a single solution,” Foodman says. Instead, he advocates a combination of policy reform and technology modernization.

“Regularly approved standard care in many cases could be exempted,” he says. “Programs could be implemented to prevent established physicians and practices from needing prior authorization on routine medications and procedures, and the requirements and denial documentation could all be improved.”

From a technology standpoint, however, Foodman is firm.

“There is no reason that all prior authorization today cannot be done electronically. There is no hurdle from a technological standpoint.”

The work that remains involves interoperability and common standards across healthcare organizations.

“Quite a lot of work has to be done around interoperability and standards need to be created and mandated,” he says. “The opportunity exists for huge improvement by getting all of the payers and healthcare providers talking to each other electronically for all prior authorization activity.”

Modern APIs, cloud platforms and standardized data exchange already exist. But it’s scaling those capabilities consistently across the healthcare ecosystem that remains the larger challenge.

Intelligent Automation Should Separate Routine From Complex Cases

Tirumala Ashish Kumar Manne, Principal Cloud Architect at Optum, believes prior authorization should function much like fraud detection or payment processing: Routine requests should happen almost instantly, while only exceptional cases receive manual review.

“Prior authorization stays slow because we treat every request the same,” he says. “Route the routine and the exceptional down different paths.”

Artificial intelligence and clinical decision support can evaluate most requests automatically.

“A system reading the clinical record against the criteria can clear the majority instantly, the moment the order is placed.”

Human reviewers would then focus exclusively on complex clinical decisions, with “the genuine edge cases” routed “to a clinician who has the time to review them well.”

He also supports broader use of provider “fast lanes”: “Providers earn a faster lane on requests where their track record proves the review adds nothing.”

Like several other Think Tank members, Manne believes technology is no longer the limiting factor.

“The barrier is not technology. It is the will to let a transparent system make the easy calls, and the shared data standards to feed it the full record.”

If those issues are addressed, he says, prior authorization becomes almost automatic.

“It stops being a queue you wait in and becomes a check that clears in the background, the way it always should have been.”

Better Data Is More Valuable Than More Software

Sriharsha Chavali, Enterprise Technology Leader at The Aspen Group, brings firsthand experience building interoperability and revenue cycle systems for large healthcare organizations. He argues that many organizations have invested in technology without fixing the underlying data problems.

“Prior authorization reform sounds great, but the data tells a different story,” he says. “I see the same failure pattern repeatedly: Requests go out, decisions come back late through disconnected portals and denials arrive with little clarity.”

Even more frustrating, providers often discover policy changes only after reimbursement problems emerge.

“We see payer-specific bundling rules and procedure-diagnosis denial patterns that were never transparent up front,” he says. “When a payer changes adjudication policy, the first signal is usually a denial spike two billing cycles later—not a notice.”

Real-time approvals and reducing low-value authorizations would certainly help, Chavali says, but they address symptoms rather than root causes.

“The real fix is machine-readable payer logic at the point of care.”

Without transparent business rules shared electronically, organizations simply continue layering new software on top of inefficient workflows.

“Until incentives change, we’ll keep layering tools onto a broken workflow instead of fixing it.”

“A radically different approach is likely needed to slay the prior authorization dragon.”

– Mark Francis, Founder and CEO of CaregiverZone, Inc.

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Legal Pressure May Accelerate Reform

While most Think Tank members emphasize technology and interoperability, Mark Francis, Founder and CEO of CaregiverZone, Inc., argues that stronger legal mechanisms may be necessary to drive systemic change.

“A radically different approach is likely needed to slay the prior authorization dragon.”

Francis suggests that providers and patient advocates consider more aggressive legal strategies in time-sensitive clinical situations.

“Obtaining temporary restraining orders and emergency injunctions hits hard against the prior authorization process.”

Initially, he believes those efforts should focus on patients facing urgent treatment decisions.

“These efforts would first need to be deployed to time-sensitive health cases such as cancer treatment and organ transplantation as the urgency for action is acute.”

Successful cases could then establish broader legal precedents.

“With success, these cases can then be used as precedent to broaden out to address policy rather than individual cases.”

Francis also notes that public awareness could become an important catalyst.

“The public relations aspects could be an important component to trigger reform,” he says.

Standardization Remains the Foundation

Dr. Dmitriy Schwarzburg, Founder and Medical Director of Skinly Aesthetics, believes the industry’s priorities are becoming increasingly clear.

“One practical change would be greater standardization and automation of the prior authorization process.”

He says providers continue to lose valuable time navigating inconsistent payer requirements.

“Too much time is still spent navigating different requirements, forms and approval processes across insurers,” he says. “Simplifying those requirements could reduce administrative burden and help patients receive care more quickly.”

Like many other Think Tank members, Schwarzburg sees organizational alignment as the greatest remaining challenge.

“The biggest challenge is that insurers, providers and healthcare systems often operate with different priorities and processes.”

Until those competing incentives become better aligned, unnecessary delays are likely to continue.

“Patients and healthcare providers will continue to experience unnecessary delays and frustration,” he says.

A Roadmap for Meaningful Prior Authorization Reform

• Eliminate unnecessary prior authorizations. Review approval-rate data to identify services that can safely move to automatic approval.
• Standardize requirements across payers. Common documentation requirements and gold-carding programs reduce administrative burden without compromising oversight.
• Increase transparency. Publish approval rates, clarify denial rationale and make payer criteria easier for providers to understand.
• Build interoperable Electronic Prior Authorization into clinical workflows. Embed payer requirements directly inside EHRs using standards such as HL7 FHIR APIs.
• Digitize every prior authorization transaction. Fully electronic workflows reduce delays, manual data entry and administrative costs.
• Use intelligent automation appropriately. Reserve clinician review for complex cases while allowing AI-assisted workflows to process routine requests in real time.
• Make payer rules machine-readable. Providing structured business logic at the point of care prevents avoidable denials before claims are submitted.
• Consider policy and legal advocacy. Strategic legal challenges may accelerate reform for patients facing time-sensitive care decisions.
• Align incentives across stakeholders. Sustainable reform requires providers, payers and policymakers to prioritize timely, evidence-based patient care over administrative complexity.

The Path Forward for Prior Authorization

Despite broad agreement that prior authorization needs to improve, lasting reform will require more than incremental policy changes or new technology alone. The insights from the Senior Executive Healthcare Think Tank suggest that real progress depends on addressing the underlying issues that have long complicated the process: inconsistent standards, fragmented systems, opaque decision-making and misaligned incentives.

Perhaps the most encouraging takeaway is that many of the solutions are no longer theoretical. Electronic prior authorization, interoperable data standards, AI-assisted decision support and greater transparency are already beginning to reshape parts of the healthcare ecosystem. The next challenge is scaling those successes across the industry so prior authorization becomes less of a barrier to care and more of a seamless safeguard that supports clinicians, patients and payers alike.