AI Prior Authorization for Providers Market Map
This is part of Elion’s weekly market map series where we break down critical vendor categories and the key players in them. For more, become a member and sign up for our email here.
Prior authorizations (PA) are a necessary evil: time-consuming and frustrating, but required to get patients the care they need.
Planes, Trains, and Automobiles; or, How to Get Prior Auth
While the logic for PA is justifiable (i.e., ensuring appropriate utilization and that care aligns with evidence-based practices), the logistical burden is often crushing.
Providers must create orders, run eligibility checks, submit requests, fill out forms, send medical records, and communicate through web portals, faxes, and phone calls—all simply to get care approved.
AI-enabled solutions are emerging to reduce this administrative burden, tackling more challenging aspects of the workflow, including:
Identification of clinical criteria and documentation requirements
Validation of payer requirements against clinical data
Summarization and structuring of relevant clinical notes
Semi or fully-automated form population
Support in appealing PA denials
Initial Areas of Traction for AI
We’re seeing many new entrants in the AI-Enabled Prior Authorization for Providers space, covering use cases for both drugs and procedures:
Medications: The focus here is split between oncology drugs, specialty infusion drugs, and popular drugs like GLP-1s. (Examples: Develop Health, SamaCare, Tandem, and Latent)
Procedures, acute care, and post-acute care: This is an area of focus for health systems, but there are fewer AI-enabled vendors in this space. (Examples: AKASA, Myndshft, and Ethermed)
Others: Some vendors have chosen to focus on other, more niche areas where PAs are common. (Examples: Silna for therapy, or Synthpop for DME)
PA of the Future
Looking to the future, we see a big opportunity for AI PA to continue to improve as multiple AI-enabled tools converge.
There’s an opportunity for clinical decision support in the EHR, clinical summarization, and advancements in interoperability to better support structuring of clinical data and form-filling, further streamlining the authorization process.