Electronic Health Reporter

By Colin Banas, M.D., M.H.A., Chief Medical Officer, DrFirst.

I travel so much for work that I always have my favorite airline app front and center on my phone. Before I get to the gate, it tells me where the plane is, whether it’s on time, what’s causing a delay if there is one, and what happens next.

I just wish the prior authorization process would give doctors that same type of information. I write a prescription, submit a PA request, and then…nothing. No status bar, no explanation for a delay. Just a black hole where my patient and I wait to find out whether treatment is approved, delayed, or denied, and why.

That gap creates more than frustration. The 2025 American Medical Association PA physician survey found that 92% of respondents believe the PA process has a negative impact on clinical outcomes. When a flight is delayed, the inconvenience is annoying, but status updates keep passengers informed so they can make alternate plans. When a PA is delayed, there’s simply a void. Patients wait with no information about what’s happening or when they can expect an answer. Even worse, delays can mean patients don’t get the therapy they need in a timely manner or lead to patients giving up on treatment altogether.

Other factors contribute to prescription abandonment, of course. For example, JAMA recently published a study that explored how frequently prescriptions are rejected because of insurance formulary restrictions in the United States, and how often the rejected medicines are ultimately dispensed. It found that once rejected, only 38.6% of patients obtained the prescribed drug, and 13% received a medication in the same therapeutic class, meaning that nearly half (48.4%) received no medication in the same therapeutic class within 90 days. Half of patients giving up on therapy is an alarming rate of abandonment, and the prescriber may never know about it until the patient returns for follow-up, often months later. But that’s a story for another article.

Prior Authorization Rules Need to Go Beyond Turnaround Time

Now, the regulatory landscape is shifting. The federal HTI-4 final rule established the certification criteria for electronic prior authorization last year, and CMS-0057-F is requiring payers to answer an urgent PA request within 72 hours and a standard request within seven calendar days.

That’s a real improvement, and it’s overdue. But as with an airline flight, landing on schedule is just one part of the journey. While PA turnaround time tells you when the determination arrived, it tells you nothing about turbulence in the process, such as whether the submission included everything the payer needed or was sent back due to missing information. One source of turbulence that needs to be curtailed is the Direct Data Entry (DDE) portal exception. By setting a firm sunset date for this exception, CMS will ensure providers won’t stay stuck in legacy workflows. Moving away from portals is essential to reducing clinician burnout and improving patient access to therapy.

Another cause of turbulence right now is the role of AI in PA decision-making. Modern aircraft fly most of a routine flight on autopilot. That’s the whole point of the system. What’s non-negotiable is that a licensed pilot stays in the seat, is accountable for the outcome, and is required to take manual control the moment something falls outside the routine. In other words, the FAA doesn’t ban automation, it just makes sure there’s a “human in the loop.”

PA has no equivalent standard. The rules don’t require disclosure of whether a denial for a specialty medication or complex therapy had a clinician in the seat or was processed entirely on autopilot. Nor do they require reporting on how often the automated denials get reversed once a physician or patient appeals.

Healthcare policymakers are increasingly interested in putting AI to work reviewing claims faster, and I think that instinct is basically right. An algorithm that catches a documentation gap before a human reviewer gets to it is a genuine improvement. But physicians and patients should know whether AI played a role in accepting or denying a PA, just as physicians owe it to our patients to disclose when we’re using AI in the exam room to help draft notes.

What Prior Authorization Transparency Should Look Like

In formal comments to CMS on their proposed rule, we recommended payers be required to publicly report PA metrics and provide specific, actionable reasons for every denial. We also urged CMS to maintain the October 1, 2027, deadline for payer compliance so the industry moves in lockstep rather than creating a patchwork of fixes. With clear metrics on PA status, response times, denial and reversal rates, and disclosure of AI’s role in the decision, physicians and patients could finally see what’s happening inside the process.

Unfortunately, rulemaking won’t resolve this situation. The infrastructure behind e-prescribing was built for a simpler transaction—send a script, fill a script—not for the web of rules, exceptions, and approvals that PA now requires. Reporting requirements can tell providers a delay happened, but they can’t fix the plumbing that caused it. What’s missing is a connective layer linking providers, pharmacies, PBMs, and patients so that status, reasons for denial, and appeals don’t get stuck in portals and fax queues. Industry is starting to respond to this need.

My airline app works because airlines, air traffic control, and airports all agreed to share data in real time. Prior authorization needs that same agreement. Until providers, pharmacies, and payers are reading from a common, transparent feed, patients will keep sitting at the gate without the information they need to guide the next leg of their journey.