Closing the AI gap: How intelligent prior authorization is transforming health care

Health plans are facing growing economic pressure due to rising utilization of medical services and escalating health care costs. These challenges are compounded by a significant lag in adopting AI technology, which has left health plans struggling to optimize utilization management (UM) and achieve necessary spending targets. A recent McKinsey report found that the artificial intelligence (AI) adoption gap is costing health plans up to 25% in potential administrative savings—representing billions of dollars left on the table. Beyond financial losses, this gap in adopting AI hinders the ability to leverage the technology to improve patient outcomes.

Utilization management is crucial for ensuring that patient care is necessary and cost-effective, yet it remains a significant challenge. The lack of AI-driven automation in UM leads to time-consuming processes that frustrate providers and delay patient care, particularly in urgent cases. This inefficiency not only impacts patient outcomes but also strains administrative resources, intensifying financial pressures and unnecessary burden on providers.

To address these challenges, forward-thinking health plans are turning to intelligent prior authorization technology. This solution leverages AI, machine learning (ML), and evidence-based clinical intelligence to automate and optimize prior authorization workflows. By doing so, it accelerates decision-making, improves patient care coordination with providers, and unlocks substantial ROI—helping health plans close the AI adoption gap and achieve meaningful results.

How exactly does intelligent prior authorization close the AI adoption gap, and why is it essential for health plans to embrace this technology now?

Driving better care quality

Fundamentally, leveraging AI in health care should be focused on improving patient outcomes, and intelligent prior authorization plays a pivotal role. By integrating AI and ML with the best health care data, this technology enables more informed, timely decisions that enhance care quality and speed up outcomes. By authorizing multiple service requests for a single patient care path, AI streamlines workflows, making the process more efficient and less error-prone, reducing unnecessary procedures.

Additionally, “clinical nudges” are another important feature, providing real-time notifications that guide providers toward value-based care decisions. These alternative treatment options, such as lower-cost or in-network services, offer real-time estimates of treatment approvals based on patient data and health plan guidelines. This bolsters collaboration between providers and health plans, ensuring that prior authorization criteria are clearly understood and followed.

Enhancing provider experience and breaking down silos

Collaboration is essential for delivering high-quality health care, yet traditional UM systems are often siloed, slowing and sometimes even blocking communication between the various stakeholders. Intelligent prior authorization helps break down these walls by enabling real-time data sharing and communication across providers, health plans, and patients. As a result, provider burden and friction are reduced or eliminated with much less manual and faster processes.

AI also improves the prior authorization experience for providers by enabling “touchless authorization,” a frictionless process that eliminates the need for manual prior authorization input. Achieving this requires innovative use of AI, along with seamless interoperability across health care systems. Health plans using intelligent prior authorization platforms are achieving 38% completely touchless prior authorization submissions, reducing provider intake time and expense by 61%.

Intelligent prior authorization also expedites requests by integrating with electronic medical records (EMRs) and other systems, allowing clinicians to submit requests directly through the EMR. This speeds up the prior authorization process, improves decisions by including patient safety considerations, and ensures all relevant information is available in real time, thereby reducing the providers’ administrative burden.

Another promising development in this area is early trend signal reporting, which projects utilization and spending based on prior authorization data. This approach enables collaboration with high-utilization providers to improve medical utilization trends and enhance care quality. It also helps financial staff anticipate changes in spending months earlier than claims data comes in.

Real-world results

The benefits of AI in prior authorization are not just theoretical; they are being realized daily. AI transforms the prior authorization process, freeing clinical staff to focus on more impactful work, reducing administrative tasks, and ultimately improving patient care. Large language models (LLMs) guide reviewers to pertinent information in clinical documents, significantly reducing review time and improving efficiency. Some health plans using this technology are achieving actual AI-driven results:

• 61% reduction in provider time to input requests
• 38% completely touchless authorization intake
• 89% immediate, automatic approvals

Related: Health plan prior authorization change bill returns to Senate

AI also improves care management, with predictive models targeting clinical interventions and directing patients to the best and safest care. This approach should always be grounded in a collaboration between clinicians and ML engineers. While these advancements push health care forward, the human element remains central to meaningful change.

Automating and optimizing the prior authorization process with intelligent technology closes the AI adoption gap, delivers ROI for health plans, significantly enhances care quality, and reduces the administrative burden for providers. For health plans, adopting intelligent prior authorization is not just beneficial—it’s critical for staying competitive and achieving significant savings while improving patient care.

Dr. TraciGranston serves as the Vice President of Clinical Strategy for Musculoskeletal at Cohere Health. Dr. Granston is an orthopedic surgeon based in Washington who specializes in hand surgery and practices at Proliance Orthopedic Surgeons.