Prior authorization has been under intense scrutiny in recent months as frustration brews among clinicians and legislators aim to curb the use of AI technology in the practice.
Here are five recent developments reshaping the way prior authorization is deployed in healthcare settings and payer claims processing:
1. Democratic lawmakers introduced resolutions in the House and Senate to overturn CMS’ Wasteful and Inappropriate Services Reduction (WISeR) model, an AI-assisted prior authorization initiative under traditional Medicare..
CMS launched WISeR at the start of 2026, with plans to run the model through the end of 2031 in Washington, New Jersey, Ohio, Oklahoma, Texas and Arizona. The model applies prior authorization requirements to select traditional Medicare services and relies on for-profit contractors using AI tools to process requests and reviews. Democrats have attempted to block WISeR through multiple legislative avenues since CMS announced the model last June, including appropriations amendments and standalone legislation, without success.
2. Last year over 60 major health insurers pledged to streamline prior authorization processes — but few physicians think these pledges have made a difference in PA burden, according to the American Medical Association’s “2025 AMA Prior Authorization Physician Survey” released May 13. Recently, UnitedHealthcare reaffirmed this pledge, saying it would pare down PA for 30% of applicable services.
Despite the recent promises and the 2018 “Consensus Statement on Improving the Prior Authorization Process” being released nearly 7 years before this survey, physicians report health plans have made little progress honoring their commitments. Only 16% of physicians working with UHC and 16% working with Cigna say those changes actually reduced the number of PAs they complete.
3. Iowa Republican Gov. Kim Reynolds signed a law May 13 that enacts prior authorization reforms and prohibits insurers from penalizing providers for out-of-network referrals, according to the Iowa Hospital Association.
Under the law, while initial prior authorization reviews can be done by AI, these algorithms and systems cannot be the sole basis for determining denials, downgrades or delays. Health insurance carriers cannot impose fines or other financial penalties due to a provider’s referral to an out-of-network provider, either.
4. North Carolina lawmakers are also deliberating a bill that would limit AI’s use in healthcare, primarily in relation to how it is used in billing and claims denials. House Bill 565 would prohibit payers from using AI as the sole basis for denying healthcare claims or prior authorization requests.
5. PA continues to be a significant burden for physicians and patients, according to the AMA’s recent survey. Ninety-three percent of physicians reported that PA can cause care delays at least some of the time, while 82% reported that PA can at least sometimes lead to patients abandoning treatment plans. Notably, zero physicians in the survey said PA never caused treatment plan abandonment.
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