The process of gaining pre-approval for medical care from health insurers can be a lengthy and frustrating experience for patients. The use of prior authorization is intended to prevent overuse and unnecessary spending on services or technologies, but it often leads to delays in care, causing patients to abandon recommended treatments while waiting for approval.
Artificial intelligence (AI) has been proposed as a solution to expedite the prior authorization process, but its implementation raises concerns about the potential increase in wrongful denials of health insurance coverage.
According to a 2025 American Medical Association survey, 61% of physicians are worried that AI will exacerbate denials of necessary treatments. The AMA advocates for requiring insurers to provide detailed clinical reasoning to justify denials of coverage and increased transparency regarding AI algorithms.
Health policy analyst Camm Epstein emphasized the importance of using AI to make appropriate care easier to approve, not necessary care easier to deny. ‘The goal should be to streamline the process while ensuring that patients receive the care they need,’ Epstein said.
The Trump administration is currently piloting a program in six states that uses AI to reduce unnecessary medical spending. However, it remains to be seen whether this new approach will help fix the complex system of prior authorization. The public views prior authorization as a major burden, with millions of full or partial claim denials issued annually based on prior authorization in Medicare Advantage.
The introduction of AI-powered prior authorization raises concerns about the potential for increased care delays and denials. Critics argue that integrating AI into the process may lead to more wrongful denials of necessary treatments. The government and private insurers have tried to make improvements, including a rule issued by former President Joe Biden’s administration in 2024 that required insurers to make certain prior authorization decisions within 72 hours for urgent requests.
The Centers for Medicare and Medicaid Services (CMS) has begun a demonstration project called WISeR, or Wasteful and Inappropriate Service Reduction Model, which uses AI to reduce waste and fraud in original Medicare. However, critics argue that this shift may not be good for patients, as it may lead to more denials of necessary treatments.
The use of AI in prior authorization is a complex issue, with both potential benefits and drawbacks. While AI may help expedite the approval process, its implementation raises concerns about the potential increase in wrongful denials of health insurance coverage. As the healthcare system continues to evolve, it is essential to carefully consider the impact of AI on patient care.
**The AMA’s Stance**: The American Medical Association has expressed concerns about the use of AI in prior authorization, citing the need for increased transparency and accountability. ‘We must ensure that AI algorithms are transparent, explainable, and auditable,’ said Dr. Gerald Harmon, AMA President.
**The WISeR Project**: The Centers for Medicare and Medicaid Services (CMS) has launched a demonstration project called WISeR, which uses AI to reduce waste and fraud in original Medicare. However, critics argue that this shift may not be good for patients, as it may lead to more denials of necessary treatments.
**The Future of Prior Authorization**: As the healthcare system continues to evolve, it is essential to carefully consider the impact of AI on patient care. While AI may help expedite the approval process, its implementation raises concerns about the potential increase in wrongful denials of health insurance coverage.
Source: Original article