The Monster in the Middle
- carbesman
- Nov 19
- 6 min read
Updated: 3 days ago
Why Prior Authorization Wrecks the Patient Experience, and Why Everyone’s Trying to Tame It
Paul Schrimpf, Christine Arbesman
Every industry has a process that looks small on paper but shapes everything around it. In healthcare, that process is prior authorization. It is the quiet monster that hides between doctors, payers, and patients, invisible to most until it strikes. When it does, it does not just delay care; it unravels trust, burns out staff, and corrodes the very idea of a coordinated patient journey.
Most healthcare companies say they are fixing “the patient experience,” but they usually mean the transactional moments such as scheduling, messaging, or waiting room comfort. Few look at the experience across the journey. Fewer still focus on the intersections where clinical intent meets administrative burden and payer logic. That is where prior authorization lives and where, for many, the entire care experience breaks down.
The Hidden Traffic Jam of Care
To understand why prior authorization is so destructive, you have to picture the patient journey not as a line but as a set of converging roads: the provider’s workflow, the payer’s workflow, the therapy journey and the patient’s life. Every time they cross, friction appears.
Robert Laumeyer, who leads AI product work at Availity, described seeing that dysfunction firsthand. A close friend couldn’t get life-changing treatment approved, even after being properly diagnosed at Mayo Clinic. “When you’re sick, you don’t need another headache,” Laumeyer said. “That’s not what you need, right? Let’s make that easy on the people who are sickest. And those are the people in prior auth.”
That experience led him to build systems that make the process understandable to the humans actually using it, and not the theoretical doctor on a form. “No doctor is submitting a prior auth,” he said. “Anyone who thinks that is misinformed. There’s probably two submitted out of ten million in a month by an actual doctor.” What happens instead is a maze of office staff, case managers, and clinical reviewers who all speak different languages.
Laumeyer’s focus at Availity has been to reduce cognitive load and create shared understanding. The company now translates payer rules into checklists that make sense to clinical users. “Originally, those forms were written by a doctor and a lawyer locked in a room, and I don’t think they gave them any food,” he joked. “It came out horrible.” By simplifying that language, Availity not only improves efficiency but also restores a sense of dignity to the patient journey.
The Empathy Gap in Automation
Technology has made prior authorization faster, but not necessarily better. Many solutions digitize the same broken process instead of redesigning it around real users. “I’m shocked at how many healthcare technology companies have no nurses or clinicians on staff,” Laumeyer said. “How do you make a clinical product without an MD or RN telling you how it actually works?”
That empathy gap ripples outward to patients. As Frank Harvey, CEO of Surescripts, explained, “If we want to fix prior authorization, we can’t just make it faster. We have to make it invisible.” Surescripts’ nationwide network sits at the intersection of prescribing and payer information, where the problem often begins. When a physician orders a medication, the system checks coverage, formulary, and benefit design, all in seconds. “It’s about giving prescribers the visibility they need at the point of care,” Harvey said. “The more uncertainty we remove upstream, the fewer frustrations downstream.”
Both Laumeyer and Harvey point to the same truth: speed is not the same as experience. A faster rejection is still a rejection. Meaningful improvement comes only from anticipating confusion and preventing misalignment before it happens. As Laumeyer noted, “Accuracy matters. You cannot afford to be wrong even 30 percent of the time in healthcare. The system has to be observable, explainable, and in human terms.”
The M&A Rush to the Middle
In the past 24 months, the market has noticed what clinicians and patients have known for decades: the entire healthcare experience depends on fixing prior authorization. That realization has triggered a wave of mergers and acquisitions.
MyndShyft, for example, was acquired by DrFirst in early 2024, signaling how high-performing prior authorization platforms have become strategic assets for larger health IT and medication management firms. MyndShyft’s platform automates both the submission and determination processes, translating payer criteria into structured logic that reduces manual review. Its acquisition gave DrFirst deeper reach into payer/provider workflows, extending beyond e-prescribing and medication management into the broader care authorization process.
Analysts see this as part of a broader land grab. From Availity’s own acquisitions and platform expansions, to Surescripts, Change Healthcare, and Experian Health investing heavily in automation layers that promise transparency and real-time decisioning.
Why the rush? Because prior authorization is no longer just an administrative bottleneck. It has become the central control point for value based care, network efficiency, patient access, and payer compliance. Whoever solves it effectively owns the intersection between clinical care, revenue cycle, and payer oversight, which is a trillion dollar crossroads. For reference, according to the Commonwealth Fund, U.S. healthcare administrative spending surpassed 1.25 trillion dollars in 2023, representing nearly 27 percent of national health expenditures.
Investors also see that the technology stack for prior authorization is decades behind. Data fragmentation, inconsistent payer rules, and incomplete EMR integrations make it the perfect target for machine learning, interoperability APIs, and natural-language processing. The CAQH Index (2023) estimates that only 37% of prior authorization transactions are fully electronic, leaving roughly 160 million manual submissions each year and generating an avoidable cost of $450–500 million annually. But as Laumeyer cautions, “There are problems where you can’t afford errors, and many of those problems are in healthcare. AI can recommend — but not decide. Not yet.”
The most successful acquirers are pairing automation with human centered design and involving clinicians rather than removing them from the loop. That is why DrFirst through MyndShyft, Availity, and Surescripts each describe their tools not as replacements but as orchestrators, systems that guide rather than override.
Where Patient Experience Really Breaks
For patients, prior authorization is rarely visible until it blocks something vital: a surgery, a diagnostic scan, a medication refill. But for providers, it’s a daily grind that saps time, trust, and emotional bandwidth. The American Medical Association estimates that 93% of physicians report delays in care due to prior authorization, 86% say the burden is “high or extremely high,” and one in three report that it has led to serious adverse events for their patients (AMA 2024 Physician Survey).
Each request also consumes valuable staff time. The MGMA 2023 Operations Survey found that practices complete an average of 45 prior authorizations per physician per week, requiring 14 hours of staff labor and roughly $10 billion in administrative costs annually. These are hours taken directly from patient care.
The irony is that prior authorization was built to protect patients, and to prevent unnecessary or unsafe care. Yet the process designed to uphold clinical integrity has become the greatest threat to it. Each delay adds friction, anxiety, and cost. Each denial chips away at the bond between doctor and patient. It’s the system’s way of saying: we don’t trust you.
As Harvey explained, “When you give providers real-time visibility into what’s covered, you restore trust. You give them back control.” That sense of control — of clarity and predictability — is what every healthcare experience ultimately depends on.
The Intersection as the Opportunity
If there’s a reason so many companies are chasing the prior-auth problem, it’s because it touches everything: patient access, provider satisfaction, payer cost, and compliance. Fix it, and you fix the patient experience in ways that no new app or portal ever could.
The companies leading the next chapter — from Availity’s clinician-centered design to Surescripts’ transparency to MyndShyft’s automation logic — are moving toward a shared philosophy: the best technology isn’t the most advanced ; it’s the most humane.
Prior authorization may be the monster in the middle, but it’s also the map to a better system. If healthcare can finally tame it — by aligning experience, empathy, and efficiency — we might stop treating it as paperwork and start seeing it for what it really is: the crossroads of trust in healthcare.
Acknowledgements & Citations
This report draws insights and direct quotes from:
Healthcare Rap. Episode 311 featuring Frank Harvey (CEO, Surescripts), hosted by Jared Johnson, April 2024.
Microdosing with Paul Schrimpf. Season 10, Episode 9 featuring Robert Laumeyer (Availity), 2025.
American Medical Association. 2024 AMA Prior Authorization Physician Survey.
CAQH. 2023 CAQH Index: Closing the Gap in Healthcare Administrative Efficiency.
Medical Group Management Association (MGMA). 2023 Operations and Prior Authorization Survey Report.
Commonwealth Fund. U.S. Health Care Spending and Administrative Waste, 2024.
DrFirst. Press release: “DrFirst Acquires Prior Authorization Provider MyndShyft,” 2024.
MyndShyft. Press materials and industry coverage, 2024–2025.
Availity, Surescripts, Change Healthcare, and Experian Health. Press releases on electronic prior authorization and interoperability initiatives, 2023–2025.