AI in Healthcare Sparks Prior Authorization Concerns

2025-03-22 digitalcare

United States, Saturday, 22 March 2025.
Over 60% of physicians report AI tools contribute to prior authorization denials, raising governance and regulation concerns.

The Growing Crisis in Healthcare Authorization

The healthcare industry faces mounting challenges as artificial intelligence systems increasingly influence patient care decisions. Recent data reveals that 90% of physicians report prior authorization processes negatively impact patient outcomes, with 80% witnessing treatment abandonment due to delays [4]. These concerns have intensified following the March 17, 2025, death of UnitedHealthcare’s CEO Brian Thompson, which has sparked renewed debate about insurance practices and AI-driven decision-making [3].

The Heavy Toll of Manual Processing

The current system places an enormous burden on healthcare providers, with physicians spending over 14 hours per week managing prior authorizations instead of treating patients [4]. Healthcare plans collectively spend more than $18.4 billion annually processing these requests, with 87% still handled through outdated methods like fax and phone calls [4]. This inefficiency has resulted in 92% of care delays being directly linked to administrative bottlenecks in the authorization process [4].

Industry Response and Regulatory Changes

Some organizations are taking proactive steps to address these challenges. On March 18, 2025, Optum Rx announced the elimination of prior authorizations for approximately 80 drugs treating conditions such as high cholesterol, lung disease, and multiple sclerosis [5]. Meanwhile, state legislators are introducing new oversight measures. Iowa’s Senate File 562 now requires health carriers using AI for utilization review to ensure decisions are not solely based on group datasets and do not discriminate against patients [7].

Future Outlook and Security Concerns

As the healthcare sector navigates these changes, cybersecurity remains a critical concern. Currently, 56% of healthcare professionals identify external data breaches as their top risk, while only 48% of organizations audit high-risk areas [6]. Looking ahead, the Centers for Medicare & Medicaid Services will enforce new rules by January 2026, requiring urgent prior authorization requests to be processed within 72 hours and standard requests within seven days [4]. These changes aim to streamline processes while maintaining patient safety and care quality.

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Artificial Intelligence Prior Authorization