Agentic AI’s Untapped Power in Streamlining Prior Authorizations
by
Ashish Nangla - July 4, 2025
The original goal of prior authorization was to help keep healthcare costs down, not to get in the way of timely, high-quality care for patients. But for most providers today, it is still one of the most annoying and out-of-date parts of the revenue cycle. Fax machines, paper forms, and hours of back-and-forth communication with payers are still slowing down administrative teams, delaying treatments, and making things worse for both patients and providers.
The 2024 AMA Prior Authorization Physician Survey found that an astonishing 94% of doctors believe that prior authorizations hurt patient outcomes. Even more worrying, 82% say it makes patients stop treatment altogether at least sometimes because of the wait, the burden, or the confusion in the process.
This isn’t just a problem in the clinic. It’s also a business and money issue. Prior authorizations take up a lot of time, lower staff productivity, and cause problems at every step of the care process. So, what do we do next?
As health systems face more and more pressure to cut down on paperwork and make it easier for patients to get care, a lot of people are asking the same thing: Can AI really change the prior authorization process and finally turn it from a roadblock into a breakthrough?
Let’s Talk About the Prior Auth Challenges First:
- No real-time insurance verification prior to appointment scheduling
Front-desk teams often don’t know what’s going on without an automated insurance eligibility check at the time of scheduling. This causes delays, last-minute cancellations, or services to be denied because of coverage issues, which hurts both the patient experience and the integrity of the revenue. - Manual form-filling prone to human errors
When staff have to manually enter patient data into different systems, there is a greater chance of typos, missing fields, and records that don’t match up. These mistakes can slow down prior authorizations, make claims less accurate, and take a lot of time to fix. - No system to track pending or denied requests
Without a central dashboard or workflow tool, it’s easy for prior authorization statuses to get lost in emails or payer portals. Because of this, teams spend hours looking for updates, missing deadlines, and not following up on requests that have been denied or are getting older. - Struggling to keep up with the constantly changing payer rules
Each payer has different rules for documentation, coding, and submitting claims, and these rules change all the time. When you have to guess to stay compliant, you end up with rejections and resubmissions that cost you money. - Appeals being slow due to staff overload
When denials happen, the staff who are already busy have to make the paperwork for appeals. Without automation to help gather medical necessity data or previous notes, appeals take longer or don’t happen at all, which means lost revenue.
What if 16-minute submissions became 60-second automations? Tune in to discover how Agentic AI is making it possible.
The Actual Price of Today's Prior Authorization Process
Prior authorization isn’t just a struggle; it also wastes a lot of time, money, and resources in the healthcare system as a whole. Let’s take it apart:
- Time for Insurance Approval: It usually takes payers 3 to 5 business days to respond, which causes delays in care and makes patients angry.
- Hours Spent Manually: Staff spend more than 15 hours a week chasing approvals, which is time that could be spent on more important tasks.
- Denial Rate: Almost 40% of previous authorization requests are denied, which means they have to be redone, appealed, or worse, they have to stop treatment.
But these delays and problems don’t just affect care; they also cost a lot of money.
The American Medical Association (AMA) and the Medical Group Management Association (MGMA) say that practices lose between $11,000 and $13,000 per doctor each year because of problems with prior authorization. That includes lost payments, delays, rework, and staff time. When you add that up for a whole health system, the cost quickly becomes too high to handle.
Before vs After: Prior Authorization with Agentic AI
Why Agentic AI Is the Answer to Prior Auth Inefficiencies?
When implemented thoughtfully, AI agents could completely change the way prior authorizations are handled.
As payers become more complicated and staff shortages continue, relying on manual prior auth processes isn’t just inefficient; it’s also not going to work in the long run. Companies that use automation, plan smarter workflows, and use AI as a strategic enabler instead of just a tech add-on will be the ones that win. Here is how they help:
- Document Processing with AI
Smart language models pull relevant clinical data straight from EHRs, which cuts down on the time it takes to prepare and review charts by hours. - Matching Payers in Real Time
AI Agents automatically compare each case to the most up-to-date payer rules, making adjustments as policies change and cutting down on guesswork. - Automated Submission and Tracking of Status
Automation takes care of everything, from filling out forms to attaching clinical documents and keeping track of response statuses. This means you can always see where each request is. - Checks for errors and built-in validation
AI checks submissions before they get to the payer, marking any data that is missing or wrong. This greatly increases the chances of getting first-pass approval and cuts down on expensive denials.
Here What’s the Future of Prior Authorization Looks Like
Looking ahead, we can see a future where 90% of all prior authorizations are processed touchlessly moving from submission to approval without any human intervention. Of course, there will still be a small percentage of complex edge cases that require human review. But already, Agentic AI is playing a transformative role in boosting efficiency, reducing costs, and improving patient satisfaction. And it’s only going to get better as the models evolve. Curious how this could work within your existing workflows? Let’s talk. The OpenBots team is here to help you explore what’s possible.
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About Ashish Nangla
An InsureTech Leader with more than 16 years in the Insurance & Financial Services industry, Subject Matter Expert in User Experience (UX), Blockchain (Distributed Ledger including Ethereum, Hyperledger, Quorum, Corda), Artificial Intelligence (AI) & Machine Learning, Predictive Analytics, Chat Bots, Internet of Things (IOT), Usage Based Insurance and Cloud. Ashish is an Avid supporter of the technological evolution and is constantly exploring the possibilities of how technology and innovation can be leveraged to add more value businesses and their processes. At OpenBots, Ashish’s vision is to democratize enterprise RPA by eliminating bot license costs and make automation and the benefits that come with it more accessible to all.
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