Prior authorization is a common requirement in many healthcare places across the United States. It makes sure that prescribed treatments fit with insurance coverage rules, help keep costs down, and stop unnecessary treatments. But the prior authorization process is a big administrative burden for healthcare providers. Delays and denials in prior authorizations can interrupt patient care, raise operating costs, and upset both patients and providers.
Medical practice leaders know there is growing pressure to cut administrative work and improve workflow. AI has become a strong tool here, offering automated review and processing. However, using AI more often has caused worries about relying too much on machine-made decisions without enough human checks. A 2025 survey by the American Medical Association (AMA) showed that 61% of doctors worried about AI\u2019s effect on prior authorization denials. They pointed to raised risks for patient safety and higher healthcare costs.<\/p>\n
AI systems can do tasks like claims review and routing approvals faster than people, but they are not perfect. Algorithms depend on fixed rules and past data. This might miss the details of what a patient needs. In prior authorization, strict AI use can cause wrong denials or approvals. This may harm patients or waste healthcare money.
Praveen Kotha, Chief Technology Officer at True Rx Health Strategists, says, “AI and technology can help smooth the PA process, but human clinical review is very important \u2013 especially because mistakes can affect health and costs.” This shows that strong human clinical checks must be part of AI workflows.
Doctors, nurses, or care coordinators add this important level of review and give personal advice. For example, in handling diseases like diabetes, pharmacy benefit managers (PBMs) such as True Rx have shown how mixing clinical consultations with AI works well. They use medication monitoring programs, including special tests checked by clinical pharmacists, to find risks that AI might miss.
This mix of technology and human clinical judgment helps make safer choices about medicines and treatments. Patients often feel better and less worried when human helpers are there during the prior authorization process. One True Rx patient said, “I was to the point of wanting to cry and pull my hair out or stop taking my medication. I was at a loss, but you have relieved so much pressure. I appreciate you following up.”<\/p>\n
AI has been used more and more in prior authorization workflows in hospitals and medical offices. About 46% of U.S. hospitals now use AI in revenue-cycle management (RCM), which includes prior authorization and other administrative work. Around 74% use some form of automation like robotic process automation (RPA) to cut manual tasks and make workflows smoother.
There are real examples of better efficiency and productivity. The Fresno Community Health Care Network used AI tools to check claims before sending them. This cut prior-authorization denials by 22% and denials of uncovered services by 18%. They saved about 30-35 staff hours a week without hiring more people. Auburn Community Hospital saw a 50% drop in cases where patients left but were not billed and a 40% rise in coder productivity.
These results show AI can reduce delays in administration. Still, there is a risk if AI is the only tool used. The AMA survey shows many doctors worry too much AI use in prior authorization can raise patient safety risks and costs.<\/p>\n
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