Many health plans are discovering that even after digitizing medical policies and implementing FHIR APIs, prior authorization turnaround times remain slow and provider frustration remains high. The reason is straightforward: digitization alone does not make medical‑necessity determinations executable by automated systems at scale.

The post Digitizing Medical Policy Alone Will Not Automate Prior Authorization at Scale appeared first on MedCity News.

Since its inception, AI in prior auth has only been at work in the commercial healthcare marketplace. Now new innovative approaches that reframe prior auth as a resource instead of a roadblock have come to Medicare via the WISeR model.

The post ‘Prior Authorization’ Has Become a Dirty Word in Healthcare, But it Might Be Medicare’s Smartest Path Forward appeared first on MedCity News.

[Sponsored] In this episode, MedCity News’ Arundhati Parmar chats with a pharmacy benefits leader and a virtual pharmacy operator about ways to modernize and scale prior authorization.

The post MedCity Pivot Podcast: Modernizing Prior Auth appeared first on MedCity News.

UnitedHealthcare is exempting rural providers from most prior authorization requirements.

The post UnitedHealthcare Expands Rural Healthcare Initiatives, Reduces Prior Auth Requirements appeared first on MedCity News.

Health insurers have reduced prior authorizations by 11% and are continuing reforms to streamline and speed up approvals, according to an announcement from AHIP and Blue Cross Blue Shield Association.

The post Insurers have Cut Prior Auth by 11% Following Commitments appeared first on MedCity News.

Technology alone won’t solve prior authorization. But refusing to adopt it guarantees the status quo: a system where insurers operate at machine speed, providers operate at human speed, and patients pay the price in delayed care.

The post Prior Authorization Is Broken. CMS’s New Rule Shows Why Regulated AI Is the Way Out appeared first on MedCity News.

With regulatory scrutiny intensifying and the demand for speed, compliance, and clarity growing, understanding the nuanced differences between AI approaches is essential for payers, providers, and patients alike.

The post Choosing the Right Methods for the Right AI to Accelerate Prior Authorizations appeared first on MedCity News.

More than 50 major insurers have pledged to streamline prior authorization starting in 2026, but providers remain cautiously optimistic and skeptical that the changes will truly reduce burden or delays in care.

The post Payers Made a Bold Prior Auth Commitment in 2025. Here’s What to Expect in 2026 appeared first on MedCity News.

Here are three things providers should consider when it comes to Medicare.

The post Changes Are Coming to 2026 Medicare Benefits appeared first on MedCity News.

[Sponsored] Take our quiz and learn more about perspectives on AI and RCM in healthcare.

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Health systems should take the lead in fixing the broken prior authorization process, said Jeff Balser, CEO of Vanderbilt University Medical Center, during a recent conference. He highlighted AI, better workflows and centralized support as ways to reduce delays.

The post Vanderbilt CEO: Health Systems Can Fix Prior Auth Without Waiting for Payers appeared first on MedCity News.

Thirteen House Democrats introduced eight bills to rein in Medicare Advantage and bolster traditional Medicare.

The post Lawmakers Introduce Multiple Bills Aimed at Medicare Advantage Reform appeared first on MedCity News.

AI and advanced analytics can help organizations move beyond incremental fixes, streamlining access and improving patient experience, without overburdening staff or budgets.

The post Simplifying Patient Access And Building Trust Using AI appeared first on MedCity News.

Guideline directed care pathways are a way to shift from transactional PA, where each service requires separate approval, to an episode-of-care model.

The post It’s Time to Rethink Prior Authorization for Chronic and Serious Conditions appeared first on MedCity News.

Cohere Health and Microsoft have teamed up to use ambient listening and AI to simplify and speed up the prior authorization process, part of a broader industry shift toward reducing paperwork and improving care at the point of service.

The post Cohere Health Teams Up with Microsoft to Advance Prior Authorization Using Ambient Listening appeared first on MedCity News.

Develop Health’s Series A funding round was led by Wing Venture Capital, and included participation from Afore Capital, J Ventures and South Park Commons.

The post Develop Health Secures $14.3M to Streamline Prior Authorization appeared first on MedCity News.

Highmark Health recently announced a partnership with AI technology company Abridge to deploy its ambient clinical documentation platform across Allegheny Health Network and co-develop a new prior authorization solution.

The post Highmark Health, Abridge Partner to Scale AI for Payers/Providers appeared first on MedCity News.

It’s a meaningful step. But declarations alone won’t fix a system still powered by fax machines, phone calls, and inconsistent rules. Real progress will require a modern digital infrastructure, aligned incentives, and coordinated action across both the public and private sectors.

The post Prior Authorization Reform Is Finally on the Table — Standards Must Be Too appeared first on MedCity News.

Without systemic redesign, these efforts risk reinforcing the same pain points that made prior authorization a flashpoint for payers and providers.

The post CMS and AHIP Isn’t the Finish Line: It’s the Starting Gun for Prior Auth Innovation appeared first on MedCity News.

By keeping our AI and ML grounded in real-world medicine, we can shape a future where prior authorization works smarter, faster, and better for everyone involved.

The post Physician-led AI: Unlocking Clinical Productivity In Prior Authorization appeared first on MedCity News.

Ochsner Health is expanding its use of Latent Health’s AI platform after its reduced medication prior authorization times to just 4-5 minutes. The technology is designed to both streamline pharmacists’ workflows as well as improve patients’ access to medications.

The post Ochsner Health Scales AI Tool After Its Cuts Prior Authorization Time to Just 4-5 Minutes appeared first on MedCity News.

Several insurers, such as UnitedHealthcare, Aetna and Cigna, pledged to improve prior authorization. These changes include streamlining decision timelines and increasing transparency.

The post More Than 50 Health Plans Commit to Simplifying Prior Authorization appeared first on MedCity News.

Cohere Health introduced a new tool for payers called Review Assist. It is meant to support health plan clinical staff with prior authorization reviews and other use cases.

The post New Cohere Health Solution Aims to Streamline Clinical Reviews for Payers appeared first on MedCity News.

Managing routine radiology does not require the administrative burden of prior authorization. Instead, health plans can implement post-service, pre-payment automated management based on clinical guidelines.

The post Managing Routine Radiology: An Opportunity to Control Costs and Improve Care appeared first on MedCity News.

The current prior authorization process in U.S. healthcare constitutes a crisis, according to Jesse Ehrenfeld, immediate past president of the American Medical Association. Prior authorization is wasting clinicians’ time, delaying care and deepening public distrust — yet, payers show little urgency in fixing this problem, he said.

The post Why One Leader Is Calling Out Insurers’ Inaction on Prior Authorization appeared first on MedCity News.

While prior authorization has made many headlines over the past year, concurrent review has not. Yet missteps in both processes leave hospitals in danger of not getting paid, which can result in higher costs being passed down to patients. 

The post What is Concurrent Review? appeared first on MedCity News.

The tools exist today to significantly reduce PA’s burden on our healthcare system, we just need to mobilize and implement them. 

The post A Four-Part Roadmap for Responsible Prior Authorization appeared first on MedCity News.

Cohere Health raked in $90 million in Series C capital, taking its total funding to date to $200 million. This round of funding cements Cohere as the emerging winner in the prior authorization tech category, according to Michael Greeley, general partner at Flare Capital Partners.

The post Cohere Health Snags $90M to Automate the Much-Maligned Prior Authorization Process appeared first on MedCity News.

Several states and insurers have gold carding programs to streamline prior authorization. However, some say they’re falling short.

The post Gold Carding Programs Are Meant to Improve Prior Authorization. Are They Working? appeared first on MedCity News.

AI tools can work together across the payer value chain, exchanging information, collaborating and making autonomous decisions based on business rules. Here are just a few examples of how their bottom lines are benefiting.

The post How Health Plans Are Adding Up Real Value From AI appeared first on MedCity News.