Epic rolls out real-time prior authorization checks for doctors

Electronic health records company Epic is launching software that instantly alerts physicians when medical procedures require prior authorization from health insurers — a step toward automating one of healthcare's most time-consuming administrative burdens.

The company is deploying the tool months ahead of a January 1 federal deadline, initially working with data from UnitedHealthcare, Aetna, and Network Health. Sixteen additional insurers are testing the system, with clinicians at Ochsner Health, Froedtert ThedaCare Health, Denver Health, and Summit Health among the first users.

Why it matters

Prior authorization delays affect millions of patients annually, forcing doctors to spend hours seeking insurer approval before delivering care. Real-time notification of authorization requirements could eliminate guesswork and speed up treatment for procedures that don't need review — though the technology stops short of automating the approval process itself.

Federal mandate drives change

The deployment stems from a 2024 Centers for Medicare and Medicaid Services rule requiring insurers to provide prior authorization requirements in machine-readable formats. Health systems currently maintain their own lists of insurer requirements or look them up case by case, creating inefficiency and potential errors.

"We are moving into this modern process of being able to remove humans out of the prior authorization request process," said Ryan Bohochik, a member of Epic's product team.

The technology queries insurers' databases to extract current requirements and will repeat those queries as patients approach the point of service to ensure accuracy.

Significant gaps remain

Knowing whether authorization is required doesn't eliminate the review process or guarantee faster care delivery. Insurers denied at least one in eight prior authorization requests last year across Medicare Advantage, Medicaid managed care, and Affordable Care Act marketplace plans, according to a KFF analysis.

The system's effectiveness depends entirely on insurers maintaining accurate data — a persistent industry challenge. Health plans have struggled to keep provider directories and other basic information current, raising questions about whether outdated data could undermine streamlining efforts.

"To have the answer be accurate, we have to make sure that the insurers are doing the work on their side," Bohochik acknowledged.

Next phase: full automation

Epic and insurers are working to digitize the next steps: automating the documentation required to establish medical necessity and submitting that information for approval. Artificial intelligence is expected to eventually extract required details from medical records, reserving human review for complex cases.

Sarah Dencker, vice president of care services at Network Health, said the technology work is prompting insurers to reconsider which services actually need prior authorization. "When you're doing the work to have the technology work as intended, it's a time to open up your books and ask: Should this service continue to require prior authorization, or should it come off the prior auth list?"

In May, CMS administrator Mehmet Oz announced a coalition of insurers, hospitals, and health records companies to further refine medical procedure review processes. Health insurers reported cutting pre-treatment claim reviews by 11% over the past year.

These details were first reported by Axios.