The following is a guest article by Ankit Jain, CEO at Infinitus
Health officials and tech executives convened at the White House to outline the contours of a new era in which patients own and control their protected health information, while dramatically reducing the cost and administrative burden of data sharing across a growing ecosystem of acute and ambulatory providers.
“For too long, patients in this country have been burdened with a healthcare system that has not kept pace with the disruptive innovations that have transformed nearly every other sector of our economy,” said CMS Administrator Dr. Mehmet Oz.
He’s right. Easy, secure, and seamless data portability is a critically important milestone on the path to real healthcare innovation, and yet it is only the first step. The Administration has a once-in-a-generation opportunity to now transform our healthcare system’s most inefficient and universally frustrating processes.
The goal of the interoperable digital health ecosystem, according to CMS, is to “build a smarter, more secure, and more personalized healthcare system.” And several weeks ago, in “America’s AI Action Plan” the Administration specifically called on healthcare to transcend a complex regulatory landscape to reduce complexity. Prior authorization falls squarely within the spirit of these efforts and is the perfect place to start.
This is an industry where broad consensus is extremely rare. When it does happen, it’s fleeting. Prior authorization is the exception to the rule. Ask patients, physicians, or health plans what they’d fix about healthcare first, and prior authorization is bound to be one of the top responses.
For patients, prior authorization often means delays in care, stress, and potentially dangerous setbacks. According to the American Medical Association, 94% of physicians say prior authorization leads to delays in necessary care. For physicians, it’s a daily exercise in bureaucratic contortion. The policy variation across plans and procedures turns every approval into a scavenger hunt for the right codes, forms, and clinical justifications. It’s why the average physician spends nearly two full business days a week just to complete 45 prior auth requests – time they want to, and should, be spending with patients.
Payers aren’t spared the documentation dump, either. More often than not, health plans deny prior auth requests not because the treatment is inappropriate, but because the initial request lacked the necessary information. That’s why 82 percent of appeals are ultimately resolved in the patient’s favor. It’s not a widespread coverage issue, but a systemic communication failure.
Prior auth feels like an intractable problem, but the solution isn’t to eliminate it. It’s to digitize it. That work starts with interoperability – not as an end itself, but as the foundation for a healthcare system that works more efficiently and seamlessly for everyone.
The healthcare industry already has a blueprint for transformation of this magnitude. The federal EHR mandate was one of the most complex digital overhauls in American healthcare history. In fact, it may have been the hardest thing healthcare has ever done. It wasn’t easy, today, the EHR has become the bedrock of modern care for clinicians and health plans.
But a common data language for prior auth would do for policy what EHRs did for patient records. The impact on patients would be especially profound.
With a common data language, payors could publish their medical necessity criteria and allow provider EHR systems to interpret those rules at the point of care. You could sit in an exam room while your physician instantly determines whether the treatment they just proposed is covered, understands what documentation is required for authorization, and can tell you within seconds whether or not it’s approved.
No phone calls necessary. No guesswork, and no delays in care.
On the payor side, a system like this would open up the floodgates for innovation. Routine requests could be programmatically reviewed by AI agents that could approve obvious cases instantly based on policy rules, and escalate edge cases for human review. These systems won’t replace humans – they’ll ensure that human decision-making is directed to the places it matters most.
Interoperability is the foundation that makes automation at this scale possible. It’s the kind of transformation CMS’ new data sharing initiative can enable, as long as it prioritizes the right use cases.
A common data language is step one. But making a framework like this work will also require a willingness among payors to adopt it. CMS is uniquely positioned to deliver both. By establishing a shared standard and requiring its use in Medicare Advantage, CMS can set the tone for the entire industry. Commercial payors will follow if it means faster approvals, fewer appeals, lower admin costs, and better relationships with providers.
The opportunity before the Administration to bring about truly generational change and create lasting reform is historic. They have the data and technology, as CMS Administrator Dr. Oz has said, but they also have the popular support to direct those resources toward fixing prior authorization.
Interoperability will be the first step. But transformation can be a speedy second.
