Will AI fix prior authorization—or make it worse?
Will AI fix prior authorization—or make it worse?
人工智能会改善“预先授权”制度，还是让情况变得更糟？
If you’re like me, you or a loved one has struggled through the process of gaining pre-approval for the medical care that your physician has recommended. Personal stories abound regarding the tribulations of patients as they go through hoops to get their health insurer to pay for certain prescription medications, medical procedures, and more. 如果你和我一样，你或你的亲人一定经历过为医生推荐的医疗服务申请“预先授权”（pre-approval）的艰难过程。关于患者为了让保险公司支付特定处方药、医疗手术等费用而四处奔波的痛苦经历，可谓比比皆是。
When used judiciously, this process—known as prior authorization—serves as a check on overuse and spending on services or technologies for which there are less costly alternatives. But a large majority of physicians voice concerns about care delays, which can cause patients to abandon recommended treatments while waiting for the insurance company to verify their eligibility and confirm that the treatment is, indeed, medically necessary. Patients who are denied care may submit an appeal, but that requires more time. 当使用得当时，这种被称为“预先授权”的流程可以有效遏制过度医疗，并减少对那些有更廉价替代方案的服务或技术的支出。然而，绝大多数医生对由此导致的护理延误表示担忧——患者在等待保险公司核实资格并确认治疗确实具有“医疗必要性”的过程中，往往会因为等待时间过长而放弃治疗。被拒绝的患者虽然可以提出申诉，但这又需要耗费更多时间。
AI might be able to help. With its ability to efficiently sort through vast reams of information, artificial intelligence could theoretically expedite approval of unambiguously allowable claims, thereby reducing care delays. However, AI-driven prior authorization is facing resistance, as it may increase wrongful denials of health insurance coverage. 人工智能或许能提供帮助。凭借高效处理海量信息的能力，人工智能理论上可以加快对明确合规的理赔申请的审批速度，从而减少护理延误。然而，人工智能驱动的预先授权正面临阻力，因为它可能会增加错误拒绝保险赔付的风险。
A 2025 American Medical Association survey of physicians revealed significant concern about the application of AI tools, with 61 percent of doctors worrying that AI will exacerbate denials of what they deem are necessary treatments. The AMA advocates requiring insurers to provide detailed clinical reasoning to justify denials of coverage, in addition to more transparency regarding AI algorithms. In an email to Undark, health policy analyst Camm Epstein wrote that “AI should be used to make appropriate care easier to approve, not necessary care easier to deny.” 美国医学会（AMA）2025年的一项医生调查显示，人们对人工智能工具的应用存在严重担忧，61%的医生担心人工智能会加剧对他们认为必要的治疗方案的拒绝。AMA主张要求保险公司在拒绝赔付时提供详细的临床依据，并提高人工智能算法的透明度。卫生政策分析师卡姆·爱泼斯坦（Camm Epstein）在给《Undark》的一封电子邮件中写道：“人工智能应该被用来让合理的医疗服务更容易获得批准，而不是让必要的医疗服务更容易被拒绝。”
President Donald Trump’s administration is currently piloting a program in six states, using AI to reduce unnecessary medical spending. But it remains to be seen whether this new approach will help fix a tortuous system. Regardless of the degree to which AI is involved, the public views prior authorization as a major burden. 唐纳德·特朗普总统的政府目前正在六个州试点一个项目，利用人工智能减少不必要的医疗支出。但这种新方法能否修复这一复杂的系统，仍有待观察。无论人工智能参与程度如何，公众都将“预先授权”视为一种沉重的负担。
In Medicare Advantage—the privately run alternative to original Medicare that now enrolls roughly 55 percent of Medicare-eligible seniors and disabled people—insurers issue millions of full or partial claim denials annually based on prior authorization. Federal government reports issued in June showed that plans sometimes even reject requests for skilled nursing and rehabilitation admissions. Erecting obstacles to medically appropriate care is viewed as a particular area of concern. 在“联邦医疗保险优势计划”（Medicare Advantage，即原始联邦医疗保险的私营替代方案，目前覆盖了约55%符合条件的年长者和残障人士）中，保险公司每年基于预先授权发出数百万份全部或部分拒绝赔付的通知。联邦政府6月份发布的报告显示，这些计划有时甚至会拒绝专业护理和康复入院的申请。为合理的医疗服务设置障碍，被视为一个特别令人担忧的问题。
Patients can request medical exemptions or appeal plan decisions, but the process is often complicated and cumbersome. NBC News reported that some patients are “stuck in prior authorization” purgatory as they “run out of time or treatment options.” A newly released Commonwealth Fund survey finds that roughly one in five American working-age adults with private insurance reported that either they or a family member were denied insurance coverage for physician-recommended medical care in 2025. Forty-one percent of people who experienced a prior authorization denial said it delayed their care, and more than a quarter reported that their health problem worsened as a result. 患者可以申请医疗豁免或对保险计划的决定提出申诉，但这一过程往往复杂且繁琐。据NBC新闻报道，一些患者因“耗尽了时间或治疗选择”而陷入了“预先授权”的炼狱。英联邦基金（Commonwealth Fund）最新发布的一项调查发现，约五分之一拥有私人保险的美国劳动年龄成年人表示，他们或其家人在2025年被拒绝了医生推荐的医疗服务的保险赔付。在经历过预先授权拒绝的人中，41%的人表示这延误了他们的治疗，超过四分之一的人表示他们的健康状况因此恶化。
The government and private insurers have tried to make improvements. A rule issued by former President Joe Biden’s administration in 2024, for example, included reforms designed to reduce delays for patients with government-run plans while streamlining the prior authorization process for physicians. It required insurers to make certain prior authorization decisions within 72 hours for urgent requests, and seven calendar days for non-urgent requests. Per Jan. 1 of this year, these timeline requirements went into effect for most health plans in the public sector. 政府和私人保险公司曾试图进行改进。例如，乔·拜登前政府在2024年发布的一项规定中包含了旨在减少政府运营计划患者等待时间的改革，同时简化了医生的预先授权流程。该规定要求保险公司在72小时内对紧急请求做出预先授权决定，非紧急请求则需在7个日历日内完成。自今年1月1日起，这些时间限制要求已在公共部门的大多数健康计划中生效。
Last year, together with insurers, the Trump administration pledged to further streamline and accelerate prior authorization processes. Private insurance companies vowed to standardize electronic requests by 2027 and to “reduce the volume of medical services subject to prior authorization” by 2026, including for common procedures like colonoscopies and cataract surgeries. 去年，特朗普政府与保险公司一道，承诺进一步简化和加速预先授权流程。私人保险公司承诺在2027年前实现电子请求标准化，并在2026年前“减少需要预先授权的医疗服务数量”，其中包括结肠镜检查和白内障手术等常见医疗程序。
Now, the Trump administration wants to further ameliorate prior authorization protocols by expanding the use of AI. This year, the Centers for Medicare and Medicaid Services began a demonstration project called WISeR, or Wasteful and Inappropriate Service Reduction Model. Using AI, WISeR is designed to reduce waste and fraud in original Medicare, aiming to decrease unnecessary procedures. The project runs through December 2031 in six states, and combines technologies such as machine learning with human clinical review to evaluate services CMS believes may be vulnerable to overuse, fraud, and abuse, including skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. 现在，特朗普政府希望通过扩大人工智能的使用来进一步改善预先授权协议。今年，美国联邦医疗保险和医疗补助服务中心（CMS）启动了一个名为WISeR（浪费和不当服务减少模型）的示范项目。WISeR利用人工智能旨在减少原始联邦医疗保险中的浪费和欺诈，目标是减少不必要的医疗程序。该项目将在六个州持续到2031年12月，结合了机器学习和人工临床审查等技术，以评估CMS认为容易受到过度使用、欺诈和滥用的服务，包括皮肤和组织替代品、神经电刺激植入物以及针对膝关节骨性关节炎的膝关节镜手术。
Although prior authorization has been used extensively in Medicare Advantage, it has rarely been deployed in original Medicare. And this shift might not be good for patients. An HHS Office of Inspector General memorandum published in 2022 pointed to more than one in 10 instances in which Medicare Advantage plans denied beneficiaries’ access to services even though they apparently met coverage rules. (Being denied access doesn’t mean patients can’t ever gain access. In 2024, for example, Medicare Advantage plans overturned 81 percent of denials upon appeal.) By integrating AI into the prior authorization process, CMS says the WISeR model will “ensure timely and appropriate Medicare payment for select items and services.” But this is not how critics see it. Before WISeR was implemented, Wendell Potter, an advocate for health insurance reform and former executive at health insurer Cigna, covered th… 尽管预先授权在“联邦医疗保险优势计划”中已被广泛使用，但在原始联邦医疗保险中却很少部署。这种转变对患者来说可能并非好事。美国卫生与公众服务部（HHS）监察长办公室在2022年发布的一份备忘录指出，在超过十分之一的案例中，即使受益人明显符合承保规则，联邦医疗保险优势计划仍拒绝了他们的服务申请。（被拒绝并不意味着患者永远无法获得服务。例如，在2024年，联邦医疗保险优势计划在申诉后推翻了81%的拒绝决定。）CMS表示，通过将人工智能整合到预先授权流程中，WISeR模型将“确保对特定项目和服务进行及时且适当的联邦医疗保险支付”。但批评者并不这么看。在WISeR实施之前，医疗保险改革倡导者、信诺保险公司（Cigna）前高管温德尔·波特（Wendell Potter）曾报道过……