Every physician has a prior authorization story. Mine involves a patient who waited two weeks for a medication I had already prescribed but they never got it. The drug was perfect for her—but insurance hadn't gotten around to approving it yet.
Prior authorization costs the U.S. healthcare system an estimated $35 billion a year in administrative burden alone, and the average physician spends 14 hours a week on it. That is a full workday (for a resident, at least). Every week.
And now it is changing fast.
CMS launched the WiSER Model—a six-year AI pilot that deploys automated PA reviews inside Traditional Medicare, and pays vendors a percentage of the savings from denied claims. Early data from Texas showed only 62% of requests approved. The Electronic Frontier Foundation has already sued CMS over it.
Meanwhile, both sides of the fight are arming up with AI. Insurers are using it to deny faster. Providers are using it to appeal faster. The algorithms argue with each other while patients wait. A $5.8 billion market has grown up around the whole mess.
I break down who hates prior auth, who loves it, why it exists in the first place, what WiSER actually changes, and what the AI arms race means for how we practice—all in my latest Huddle #Trends report.
