Prior authorization isn’t just broken — it’s unsynchronized. In this episode, Evan Martin, VP of Revenue Cycle Management at ZoomCare Inc as well as Host and Producer of The Wilshire’s IT RevCast, shares what happens when real-time care delivery meets a fragmented, rule-heavy prior auth system that can’t keep up. With just one authorization specialist covering 50 clinics, Evan paints a clear picture: today’s healthcare moves fast, but prior auth is still stumbling through a maze of plan-specific rules, outdated workflows, and underperforming automation tools.
We explore how even routine imaging, meds, and mental health services become tangled in conflicting payer policies and benefit silos. Evan breaks down the bottlenecks, the firefighting, and the policy blind spots — plus why simply layering automation on top won’t fix it. The real opportunity? An orchestrated model powered by agentic AI triages, retrieves, and routes the right information to the right place — so human teams can actually focus on patient care.
This isn’t theory. It’s the lived complexity of treating patients while waiting for permission — and what the future could look like if we finally got the process in tune.
Learning Objectives:
- Identify the systemic challenges of managing prior authorizations in urgent and same-day care models, including the limitations of retroactive workflows, staffing constraints, and plan-specific payer rules.
- Evaluate the shortcomings of current automation tools in prior authorization processes, and understand why most solutions fail to scale across benefit types, payer requirements, and care settings.
- Explore how agentic AI can enable a coordinated, human-in-the-loop approach to prior authorization, supporting better orchestration of tasks such as eligibility verification, data gathering, and submission routing.
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