In today’s fast-paced healthcare environment, one process stubbornly lags behind: prior authorization. While patient self-scheduling and same-day care are becoming the norm, the administrative machinery behind approvals remains painfully slow and fragmented. In this Office Hours session, Evan Martin, VP of Revenue Cycle Management at ZoomCare, breaks down how agentic AI could turn prior authorization from a frustrating bottleneck into a streamlined, intelligent workflow—without compromising patient care.

Same-Day Care vs. Prior Authorization Delays

At ZoomCare, 80% of patients book same-day appointments, often without contacting the scheduling department. While this model empowers patients and supports rapid care delivery, it creates a constant operational dilemma:

  • Do you treat immediately and fight for retroactive approval later?
  • Or do you delay care to secure an urgent prior authorization upfront?

Martin explains that ZoomCare prioritizes timely, quality care—even if it means battling payers afterward. This approach, however, drives a surge in retro auth requests, medical records submissions, and administrative workload.

The Retro Authorization Reality

Retroactive approvals often require turnaround within 24 hours. Some teams use standardized templates that auto-pull required clinical details for specific payer groups, but timing remains a major obstacle. Clinics may open long before or after the authorization team’s working hours, causing missed submission windows.

AI-assisted pre-grab tools could solve this by collecting, organizing, and preparing documentation in advance, allowing staff to review and finalize requests quickly.

Why Agentic AI is a Game-Changer

Traditional automation follows simple rules; agentic AI can think, learn, and adapt. It can:

  • Interpret and apply payer policies in real time
  • Make routing decisions
  • Escalate exceptions to human experts
  • Learn from feedback to improve performance

For high-volume operations with minimal staff, intelligent agents dramatically cut the time spent gathering documentation, freeing human specialists to focus on urgent, complex cases.

In-Clinic Medications and the Medical vs. Pharmacy Benefit Divide

The split between medical and pharmacy benefits creates unique obstacles. Depending on place of service and insurance rules, even routine injectables may require prior authorization or specialty pharmacy delivery.

AI tools could instantly analyze a patient’s coverage, alert providers at the point of care, and initiate the right request—while giving patients a choice between immediate treatment or cost-saving alternatives.

The Clash of Clinical Judgment and Policy

Prior authorization often pits clinical expertise against rigid payer rules. Providers shouldn’t be expected to memorize every policy update, yet they still need to prepare patients for potential costs.

Integrating AI into EHR systems could automatically scan and update payer guidelines, surfacing alerts in real time so clinicians can make informed recommendations without slowing down care.

A Blueprint for Rethinking Prior Authorization

If the system were redesigned from scratch, it would start with a simple principle: put medical judgment first. Best practices would come from specialty societies and peer-reviewed research, with retroactive reviews used to flag exceptions—not block evidence-based care upfront.

Standardizing rules across payers and eliminating policy barriers that contradict established clinical guidance would ensure that care decisions are based on science, not red tape.

Biggest Delay? Data Gathering

The greatest bottleneck isn’t submitting requests—it’s collecting and consolidating the right documentation. This is where AI can have the most immediate impact, quickly pulling required clinical details into one place for review and submission.

The Future is AI-Augmented, Not AI-Replaced

Agentic AI won’t replace prior authorization teams—it will empower them. By handling repetitive data gathering and policy checks at lightning speed, AI allows staff to focus on patient advocacy and provider support. The vision is a system where care comes first, and approvals follow intelligently, not obstructively.

Watch the full webinar on-demand to see how healthcare leaders are moving from prior authorization chaos to clear AI orchestration.