The following is a guest article by Amy Qureshi, RN, BSN, Senior Director at Citius Healthcare Consulting

Most of us have at some point left a physician’s office, finding ourselves in a juggling act of interpreting instructions, scheduling services, and factoring our health management needs into our daily lives. The concern we have for our health is often compounded by cost considerations, especially when health plan constraints such as prior authorization are involved.

Finding the answers to help us requires navigating both payer and provider websites, call centers, and documents, overshadowing our real question: How can I get the right care from the right providers that is affordable and aligns with my health goals? Too often, the technologies used to streamline processes for health plans and providers leave us, the members, without the tools we need to answer that essential question, excluding us from decision-making.

Digital Disconnects

The healthcare industry is increasingly embracing interoperability and artificial intelligence (AI) to streamline Provider-Payer transactions, including the recent efforts to reduce provider friction in areas like prior authorization. However, far less attention has been given to connecting the members in these processes, who are navigating payer information to make important decisions about their care. 

Payer investment in digital member experience is not new; digital access to health and benefit information is ubiquitous. Rather than creating a member journey that empowers decision-making, this experience is often fragmented. Due to siloed, disconnected information in various formats, members are frustrated and losing confidence in the system. At the same time, the gains made through technological enhancements are reduced.

The Erosion of Trust in Healthcare

Healthcare has traditionally been a deeply personal experience, built on meaningful relationships between patients and clinicians. Over time, however, multiple factors have eroded public trust in the healthcare system, including:

• Rising costs and out-of-pocket expenses, averaging 1,514 USD per person (2023)
• Denied claims, as high as 15% of those initially submitted
• Disparities in access to quality healthcare across different demographics

These issues magnify the hurdles Payers face in member relationships even before introducing the technology intended to improve member engagement.

Technology: Gateway or Barrier?

Today, many people rely on technology to interact with their healthcare Payers and Providers, whether they want to or not. From finding a network provider to scheduling appointments, accessing test results, submitting a question, or simply receiving text messages, digital tools are central to the experience. Tools like chatbots, voice agents, and AI-generated responses have a tremendous capacity to streamline interactions. 

These tools more often streamline operations for the Payer than the member – missing the objective to improve access to care and provide timely support. A 2025 scoping review on the challenges and gaps in individuals’ use of digital technology revealed significant evidence of digital literacy needs, access barriers, and overall dissatisfaction with use, leading to abandonment of online care services.

Public Sentiment and Opportunity for Responsible AI

Public sentiment toward Payer prior authorization and payment processes is itself a challenge. The public is equally skeptical about AI, with two-thirds of 2,039 U.S. adults reporting low trust in the healthcare system’s ability to use AI responsibly. Despite this, responsible Generative AI offers a clear path forward. 

For Payers’ prior authorization and administrative processes, it has the potential to reduce false denials and improve transparency, which enhances member experience. Thoughtfully designed AI-assisted processes enable accurate rule application and clear communication, which can deliver the desired operational value without compromising member trust when designed with a member-first approach.

Building Member Trust through Governance

So, how can health plan leaders implement AI responsibly while maximizing operational benefits? The breakthrough lies in adopting an AI governance framework that deeply integrates member context and prioritizes member outcomes. With responsible deployment, leaders can build member trust, enhance transparency, and unlock greater value from AI.

Member voices must be continuously represented in AI governance, regardless of whether the AI roadmap includes member-facing technology. Without this ongoing input, AI implementations risk falling short of key principles such as fairness, transparency, and accountability.

Using prior authorization as an example, AI initiatives may include outbound member notification automation use cases. AI automation presents a great opportunity to reduce turnaround time, but designing for operations only is insufficient. Assessing the complete member experience, including how members are informed and how they engage with their plan when it employs automated or AI-assisted authorization decisions, is critical to ensuring that these processes are transparent, explainable, and trustworthy.

Promoting Member Decision-Making

Prior authorization is a process ripe for improvement, and Payers across the country are implementing AI to relieve the complexity of rules that overwhelm their highly skilled and trained utilization management team members. Members deserve and need us to give the same credence to their experience and their digital journey.

Despite the skepticism illustrated earlier, the public perception of AI in healthcare is not entirely negative. 77% of participants in a Medical Economics survey expressed their willingness to use AI-backed services, such as remote monitoring, alerts, and virtual health assistance – underscoring how differently individuals can perceive AI when it provides value for them personally.

Designing a member-first AI strategy relies on a multidisciplinary team with direct experience in working with members. Partner with deeply experienced clinicians, operators, and technology experts to design a governance framework, shape member engagement strategies, and accelerate AI deployment with proven strategies and tools.

About Amy Qureshi

Amy Qureshi, RN, BSN, is Senior Director at Citius Healthcare Consulting, where she leads digital health, case and utilization management transformation, and population health strategy initiatives. With over two decades of clinical and operational experience, she specializes in building and integrating technology solutions with evidence-based care models that enable organizations to achieve better outcomes. Amy firmly believes that organizations that make whole person health central to their strategy will position themselves for long-term success.