01 the business
Outpatient imaging centre
4 sites, 300 scans a day
Most advanced scans need prior authorisation. Staff work through payer portals and phone queues, and requests come back for missing notes. Patients wait days for scans, and some give up.
02 before
The problem
Each payer has its own forms, portals and criteria. Staff dig through the record for the right notes and results, then wait on hold or refresh portals. Requests come back for missing information, care is delayed and some patients give up on the treatment.
- Each request takes 20 to 30 minutes of staff time.
- Many come back for missing information.
- Scans are rescheduled because authorisations arrive late.
03 the build
What the AI does
- Step 1: Spots orders that need authorisation for the patient's plan, such as imaging, procedures or specialty drugs.
- Step 2: Reads the payer's published criteria for that service and builds a checklist.
- Step 3: Pulls the matching evidence from the record, such as prior treatments tried, test results and notes, with page references.
- Step 4: Fills the payer's form or portal fields and flags anything the record does not show.
- Step 5: Tracks each request's status and alerts staff to requests for more information and to approaching deadlines.
paused: waiting for a person to approve
How it was put together
- Identified orders needing authorisation for each patient's plan.
- Turned each payer's published criteria into a checklist.
- Pulled matching evidence from the referral and record, with page references.
- Tracked status and deadlines, alerting staff to requests for more information.
04 human in the loop
Where a person stays in charge
Staff review and submit every request. Anything the record does not support goes back to the clinician, and the tool never adds clinical facts that are not documented.
- Staff review and submit every request.
- Anything the record does not support goes back to the referring clinician.
- The tool never adds clinical facts that are not documented.
05 rollout
From kickoff to live in 6–8 weeks
- Weeks 1–3Map the top five payers' criteria for the most common scans.
- Weeks 4–5Prepare packets in parallel with staff and compare outcomes.
- Weeks 6–8Use for those payers and scans, then expand.
06 after
What changes
Requests go in complete the first time, so fewer come back and patients wait less. Staff spend less time on hold and in portals, and nothing is lost between teams.
Assume 120 authorisations a day at 24 minutes each, falling to 10 minutes to review a prepared packet.
120 × 14 minutes = 1,680 minutes, or 28 staff hours a day.
What to measure
- Staff minutes per request.
- Requests returned for more information.
- Days from order to authorisation.
- Scans rescheduled for authorisation reasons.
07 evidence
What the research says
In a survey of 1,000 physicians, practices averaged 43 prior authorisations per physician per week and 12 hours of physician and staff time; 94% said it delays access to care.
Moving US healthcare admin transactions from manual to automated could save $20 billion a year; a prior authorisation takes providers about 24 minutes by phone, fax or email and 16 minutes through a portal.
08 lessons
Mistakes to avoid
- Outdated criteria. Payers change rules often; keep checklists current.
- Filling gaps creatively. Missing evidence goes back to the clinician.
- No tracking. A submitted request is not an approved one.
09 questions
Common questions
- How big is the burden?
- In the AMA's 2024 survey, practices averaged 43 prior authorisations per physician per week and 12 hours of staff time, and 94% said it delays care.
- Does it submit electronically?
- Where payers support electronic prior authorisation, yes; otherwise it fills the portal or form for staff to submit.