The Inside Story: Why Prior Authorization Is a Tech Problem Disguised as a Policy Issue

Prior Authorization: The Bottleneck No One Asked For

If you work in healthcare, you already know: prior authorization (PA) is one of the biggest headaches in the industry. What was meant to be a cost-containment measure has morphed into a bureaucratic nightmare, adding delays, frustration, and administrative bloat to an already strained system.

And here’s the kicker—most of this is a tech problem masquerading as a policy issue.

The Data Tells the Story

• 91% of physicians report that PA delays care for their patients.

• 34% of providers say they’ve had a PA-related delay result in a serious adverse event.

• 14 hours per week—that’s how much time, on average, physicians and staff spend wrangling with PA requests.

• 88% of providers say the burden has increased over the last five years, despite “streamlining efforts.”

  
  

These aren’t minor inconveniences. This is a fundamental failure of healthcare operations—and an opportunity for health tech to step up.

Where Tech Is Failing (And Who’s Responsible)

1. The Lack of Standardization Is a Joke

Every payer has its own forms, rules, and submission process. Some require fax (yes, fax in 2025!), others demand clunky portal logins, and a few have barely-functioning API integrations. This fragmentation forces providers to navigate an endless maze of inconsistent requirements.

The culprits: UnitedHealthcare, Aetna, Cigna, and Blue Cross Blue Shield—all of whom have different PA rules and processes, making it nearly impossible for providers to manage efficiently.

What needs to happen:

• Industry-wide adoption of standardized electronic PA (ePA) protocols.

• API-first interoperability that allows provider EHRs to submit and track PAs automatically.

• Real-time adjudication capabilities that eliminate the guesswork of whether a PA will be approved.

  
  

2. AI and Automation Are Still Underutilized

We have AI that can diagnose disease, but we’re still manually filling out forms for common medication requests. The vast majority of PA decisions follow predictable patterns—patterns that AI could handle in seconds.

The culprits: Epic, Cerner (Oracle Health), and NextGen—major EHR vendors who have been slow to integrate seamless AI-driven PA workflows directly into provider systems.

What needs to happen:

• Machine learning models trained on historical PA data to predict and auto-approve low-risk cases.

• AI-driven rule engines that match requests to payer policies in real time.

• Automating appeals and exception handling to reduce back-and-forth delays.

3. Real-Time Data Access Is Still a Fantasy

One of the biggest barriers to fixing PA is that providers and payers aren’t looking at the same data at the same time. A physician submits a request without knowing the patient’s latest coverage details. The insurer processes the request without full clinical context. The result? Rejections, resubmissions, and delays.

The culprits: Change Healthcare (now part of UnitedHealth Group) and Availity—two of the biggest clearinghouses that act as intermediaries between payers and providers, yet fail to provide real-time PA adjudication.

What needs to happen:

• Seamless integration between payer systems and provider EHRs to enable real-time eligibility checks.

• Automated retrieval of required documentation from existing patient records instead of endless form-filling.

• Smart alerts that notify providers when a PA is needed before they submit a prescription or order.

  
  

Why This Is a Tech Industry Failure, Not Just a Policy Mess

The health tech industry has had decades to solve this, and yet most PA solutions are still half-measures. Payers drag their feet on implementing real-time solutions, while many EHR vendors treat PA as an afterthought. Meanwhile, startups attempting to tackle the issue are hamstrung by interoperability roadblocks and slow adoption cycles.

The irony? Fixing PA isn’t even a moonshot problem—it’s an automation problem. The technology already exists, and it’s been successfully applied in industries far more complex than healthcare.

The Bottom Line

Prior authorization is broken, but it doesn’t have to be. Health tech companies, payers, and providers need to stop treating PA as an inevitable bureaucratic burden and start treating it as a solvable workflow optimization challenge.

The question isn’t whether we can fix prior authorization—it’s whether these industry giants are willing to stop making excuses and actually do it.