Healthcare providers and patients in the United States find prior authorization (PA) a big challenge. PA is a step where insurers approve coverage before some medical treatments happen. It aims to control costs and ensure proper care, but often causes delays, extra paperwork, and unhappy patients. In cancer care, the process is even more complex because quick treatment is very important.
A survey by the American Medical Association (AMA) in 2025 found that 93% of doctors said PA delays access to needed care. Also, 82% said these delays sometimes make patients stop treatment. Cancer treatments like infusions and scans need to be done quickly to help patients best.
In 2021, Medicare Advantage insurers denied or partially denied over 2 million PA requests. This caused serious problems. About 29% of doctors said PA delays or denials led to serious patient issues. These include hospital stays (23%), life-threatening problems (18%), and even disability or death (8%). Managing PA takes about 13 hours each week for many medical practices. Almost 90% of doctors report this workload causes stress and burnout, which hurts healthcare services.
One main reason for delays is the lack of standard ways to submit PA requests. Many still use phone calls, faxes, or paper forms. A 2022 report by CAQH found only 28% of PA requests were sent electronically. Most use outdated methods.
PA in cancer care is different and more complicated because of specific clinical rules, treatment types, and insurer policies. Companies like Atlas Health have made AI tools made just for cancer PA tasks.
Atlas Health created Atlas Auth, an AI-powered tool for handling prior authorizations of cancer infusion treatments. It works with Atlas Navigator to set up a standard process. It helps with tasks like authorization, checking benefits, and giving patients accurate cost estimates.
Atlas Auth uses data from many sources and AI models to make PA faster and easier. It reduces manual work for providers and payers. Ethan Davidoff, CEO of Atlas Health, said PA delays happen due to complex and manual steps by payers. Atlas Auth tries to cut these delays, help patients with costs, and lower unpaid care. It can also manage financial help for oral, injectable, and non-cancer treatments.
Even though AI helps make PA faster, health workers have mixed feelings about using it. A 2025 survey by Cohere Health showed 99% of clinicians and 96% of office staff trust AI to help reduce PA work and delays.
Brian Covino, MD, Chief Medical Officer at Cohere Health, said, “Responsible, patient-focused AI does not replace doctor choices—it supports them.” Doctors want AI to help make timely and correct decisions but keep human control.
However, 60% of doctors worry AI might cause more denials because it might rely too much on machines without enough human checks. The AMA worries that if AI is used wrongly, doctors might not be involved enough in decisions, leading to wrong denials. Such denials have already caused hospital stays and serious health problems for cancer patients.
Automation and AI can lower the paperwork burden in cancer PA. They can make the process faster and more accurate.
McKinsey estimates AI can automate 50% to 75% of the manual PA work. This could cut the wait for approvals from days or weeks to just hours or days. For cancer patients, this means quicker treatment and fewer skipped therapy sessions.
Eric Demers, CEO of Madaket Health, says good data and standard documents are key for AI to work well. Bad medical records and missing info still cause many denials. AI systems that use electronic data and set standards help providers send PA requests correctly the first time.
The U.S. Centers for Medicare & Medicaid Services (CMS) has a rule starting January 1, 2026. It requires health plans to process PA requests electronically and respond within 72 hours for urgent cases and 7 days for regular ones. This rule will speed up AI and automation adoption.
Trust needs transparency in AI PA systems. Some systems, like Availity’s AuthAI, use “Real Medical Language” (RML). This changes complex insurer rules into easy-to-understand language for doctors, payers, and staff.
Robert Laumeyer, CTO at Availity, said AI does not make final yes or no decisions. Instead, it gives doctors recommendations or notes if more info is needed. People must review all decisions to keep things fair and safe.
This “human-in-the-loop” system balances AI speed with medical judgment. It helps patients stay safe and reduces office paperwork.
Using AI in PA comes with legal and ethics issues. The Department of Justice (DOJ) is watching AI use in healthcare closely, especially for fraud and abuse in claim denials.
Deputy Attorney General Lisa O. Monaco warned the DOJ will give tougher punishments for crimes helped by bad AI use. For example, in 2020, Practice Fusion was prosecuted for using AI to wrongly influence opioid prescribing.
Healthcare groups must check AI vendors carefully. They must follow new Health and Human Services (HHS) rules about sharing AI details like training data, bias checks, validation, and how the AI will be used.
If AI is not properly controlled, it may cause harm to patients, legal troubles, and damage to the organization’s reputation.
Highmark Health runs programs like Gold Carding and Active Gold Carding to automate PA approvals based on how well providers follow care rules. Providers following clinical guidelines 99% or more get instant PA approval. This skips long manual reviews.
This approach cut administration time by up to 85%, helping schedule cancer tests and treatments faster. Active Gold Carding also supports near-compliant providers with live coaching from clinical nurses to reduce mistakes and denials.
Highmark says 84% of its PA requests are now sent electronically. They are adding AI and ambient intelligence to get near-instant PA decisions during patient visits. This makes patients wait less and improves doctor satisfaction.
Medical practice leaders see AI and workflow automation as key tools to fix PA problems. These tools reduce manual work, improve accuracy, and speed up cancer care access.
Key advantages of workflow automation include:
These features match CMS requirements and upcoming rules. They help healthcare groups get ready for better electronic PA handling by 2026.
Healthcare groups must think carefully when choosing AI-based PA tools. Important things to check include:
Using AI and automation carefully can help U.S. healthcare providers manage cancer PA better. This means less paperwork, faster treatment for patients, and improved financial results for the care system. Watching rules, ethical points, and tech updates will stay important to make sure these tools help both patients and care providers.
Atlas Auth is a purpose-built prior authorization technology solution specifically designed for cancer infusion therapy, aiming to minimize delays and improve the financial experience for patients.
It integrates with Atlas Navigator to create a standardized and scalable workflow for cancer reimbursement automation, addressing unique challenges in cancer infusion prior authorizations.
Atlas Auth includes prior authorization, benefits investigation, and accurate out-of-pocket estimates tailored to cancer infusion needs.
Healthcare providers offering cancer infusion therapy benefit from Atlas Auth by reducing care delays and improving reimbursement processes.
It addresses the complexities and manual tasks of traditional prior authorization processes that often lead to delays in cancer patient care.
AI models are used to streamline the prior authorization process by analyzing unique datasets from different sources to enhance patient and provider experiences.
Unlike general prior authorization tools, Atlas Auth is specifically designed for the unique requirements of cancer infusion therapy.
By providing accurate out-of-pocket estimates and minimizing complex processes, Atlas Auth alleviates financial anxiety for patients undergoing cancer treatment.
Healthcare systems can expect reduced care delays, minimized uncompensated care, and a more consistent patient financial experience.
Atlas Health aims to empower vulnerable populations by improving access to medical financial aid through its AI-powered platform, ensuring no patient is left behind.
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