Cohere Health Findings on AI in Prior Authorization Conflict With AMA Data

A majority of US clinicians surveyed by Cohere Health said they trust the use of artificial intelligence (AI) for prior authorizations (PAs). Cohere Health is a data collection and interpretation company that utilizes responsible AI platforms to equip health plans with AI-driven actionable insights. Its 2025 National Provider Survey on Prior Authorization, including 200 clinicians and office professionals, revealed that 99% and 96% reported confidence in AI-driven PAs, respectively.¹

PAs of medications require doctors to endure lengthy processes for approval from health insurance companies to cover patient treatments or medications. What once began as an effort for payers to spend less on brand-new, expensive medications now is often blamed for hindering physicians’ ability to treat patients efficiently.² Instead of requiring PA for only newer and more expensive medications and treatments, physicians must now endure the same lengthy process for even generic medications. Not only is the application for approval tedious for physicians, but, according to a recent survey by the American Medical Association (AMA), 93% report the process has delayed access to necessary care, and because of that, 82% say that PA can at least sometimes lead patients to abandon their course of treatment.³

“Providers are speaking loud and clear: they want and deserve a prior authorization process that is smarter, simpler, and more transparent,” Brian Covino, MD, chief medical officer of Cohere Health, said in a news release.⁴ “Our responsible, clinically trained, and patient-centric AI doesn’t replace clinical judgment—it strengthens it. By helping health plans and providers better collaborate on timely, consistent, and appropriate decisions, we reduce administrative burden, safeguard patient care, and promote equity across the system.”

Cohere Health aims to implement AI into PAs to reduce the delays in approval and increase the number of health plans that accept electronic submission, many of which still only accept requests via fax or phone.⁴ The outdated process confuses physicians and office staff, as many are unsure whether or not a health plan requires PA for a specific medication or treatment.¹ Physicians are also burdened with difficult decisions when determining a patient's treatment care because they have to consider whether a medication will be covered, but have no knowledge of the approval decision beforehand.²

The AI initiative coincides with the CMS Interoperability and Prior Authorization Final Rule, implemented under the Biden administration to streamline the PA process by improving the electronic exchange of health information.⁵ The ruling, set to take effect on January 1, 2026, will require all health plans to have a modernized PA process and system and meet compliance standards. Health plans will be required to respond to urgent PA requests within 72 hours and 7 days for standard requests. As of today, only 12% of clinicians and 7% of office personnel reported that they consistently received decisions within that time frame.⁴

While streamlining PA approvals sounds appealing to the majority of physicians and medical office personnel, the AMA survey of 1000 physicians, conducted earlier this year, found that 3 in 5 physicians were concerned that health plans’ use of AI in PAs may be increasing denials.⁶ Additionally, 1 in 3 physicians also agreed with the statement that PAs' requirements lack clinical and research-based evidence in their determination, as the AI tools have been accused of producing rates of denial 16 times higher than normal.⁶

The Risks of AI Use in PA

PA denials and delays in treatment are significantly associated with poor and sometimes even fatal or life-changing outcomes, according to the AMA survey. One in 3 physicians reported that in the last 5 years, PA denials have become more frequent. Consequently, more than 29% of physicians reported that PA delays or denials led to a serious adverse event for a patient; 23% said it led to a patient’s hospitalization; 18% said it led to a life-threatening event or required intervention to prevent permanent damage; and 8% said it led to a patient’s disability, permanent bodily damage, congenital anomaly or birth defect, or death.⁶

Data like these indicate that PA requirements can be detrimental to patients' health but also put a significant burden on physicians and hospital administration, which often have people solely dedicated to handling PAs.² On average, a practice will complete 39 PAs a week, incurring nearly 13 hours of work each week dedicated to completing PAs, leaving nearly 90% of physicians somewhat or significantly burnt out.⁶

“Using AI-enabled tools to automatically deny more and more needed care is not the reform of prior authorization that physicians and patients are calling for,” AMA President Bruce A. Scott, MD, said in a press release alongside that survey. “Emerging evidence shows that insurers use automated decision-making systems to create systematic batch denials with little or no human review, placing barriers between patients and necessary medical care. Medical decisions must be made by physicians and their patients without interference from unregulated and unsupervised AI technology.”⁶

Careful AI use in health care plans’ PA processes has the potential to reduce application burdens on physicians and reduce delays and denials in patient care. However, without proper regulation, the improper use of AI in the PA process could exacerbate preexisting barriers already faced by patients and physicians. The AMA will continue to advocate for proper reform of PA with the implementation of AI; meanwhile, Cohere Health says it is confident in its technology and the role it will play in improving health outcomes by modernizing PAs.^4,6

References

1. The hidden cost of prior authorization. Cohere Health. October 6, 2025. Accessed October 7, 2025. https://resources.coherehealth.com/hubfs/Whitepapers/The%20Hidden%20Cost%20of%20Prior%20Authorization/CH-The%20hidden%20cost%20of%20prior%20authorization.pdf

2. Berg S. What doctors wish patients knew about prior authorization. American Medical Association. September 11, 2023. Accessed October 7, 2025. https://www.ama-assn.org/practice-management/prior-authorization/what-doctors-wish-patients-knew-about-prior-authorization

3. AMA prior authorization physician survey. American Medical Association. 2024. Accessed October 7, 2025. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

4. National survey: providers trust AI for prior authorization. News release. Cohere Health. October 7, 2025. Accessed October 7, 2025. https://www.coherehealth.com/news/national-survey-ai-prior-authorization

5. CMS finalizes rule to expand access to health information and improve the prior authorization process. News release. CMS. January 17, 2024. Accessed October 7, 2025. https://www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-and-improve-prior-authorization-process

6. Physicians concerned AI increases prior authorization denials. News release. American Medical Association. February 24, 2025. Accessed October 7, 2025. https://www.ama-assn.org/press-center/ama-press-releases/physicians-concerned-ai-increases-prior-authorization-denials