Are Health Plans Finally Ready to Fix Prior Authorization, or Is This Just Another Promise?

Michael Snow, PharmD

This week, AHIP (America’s Health Insurance Plans) announced that major health insurers are making voluntary commitments to streamline prior authorization processes by 2026-2027. These commitments will benefit 257 million Americans and include standardizing electronic prior authorization, reducing the scope of claims subject to prior auth, and ensuring 80% of electronic approvals are answered in real-time by 2027. As someone who spent years managing prior authorization criteria and processing these requests, I have to ask: why has it taken this long, and more importantly, how can we actually make it work this time?

The truth is, prior authorization has been a necessary evil in healthcare. Prior authorization was designed to ensure appropriate, evidence-based care while controlling costs. However, anyone who’s worked in this space knows the current system is broken. The good news? Health plans are committing to adopt FHIR® APIs and standardized data submissions, which represents a fundamental shift toward interoperability. The challenge? Making sense of the massive amounts of clinical data these systems will need to process efficiently and accurately.

This is where artificial intelligence becomes not just helpful, but essential. AI excels at exactly what prior authorization reform needs most: structuring unstructured data, applying complex clinical criteria consistently, and processing information at scale. Imagine AI systems that can instantly parse clinical notes, extract relevant patient history, and match it against evidence-based guidelines, all while learning from patterns to improve accuracy over time. Instead of pharmacists spending hours digging through medical records to determine if a patient meets criteria for a specialty medication, AI can pre-process this information and flag only the cases that truly need human review. This isn’t about replacing clinical judgment; it’s about giving healthcare professionals the structured, relevant information they need to make time-sensitive decisions.

The health plans’ commitment to real-time responses and standardized processes creates the perfect opportunity for healthcare organizations to leverage AI-powered solutions. At Epidaurus Health, we specialize in exactly this challenge – using artificial intelligence to structure clinical data and streamline complex healthcare processes. Whether you’re a health plan looking to meet these new commitments or a provider group preparing for faster turnaround times, we can help you harness AI to transform your prior authorization workflows.

Ready to move beyond promises and implement real solutions? Visit us at https://www.epidaurus.health to learn how we can help you turn these industry commitments into operational reality.