Prior authorization at machine speed: an agent reference architecture for payers

Prior authorization (PA) is a $35B annual administrative burden, the leading cause of physician burnout in surveys, and one of the few healthcare workflows where every stakeholder — payer, provider, patient — wants the process to be faster.

Why it's hard for traditional automation

Reference architecture

1. 1.Intake agent.
2. 2.Clinical evidence agent.
3. 3.Policy reasoning agent.

Governance is the deal-breaker

No payer ships PA automation without four guardrails: full audit trail of every prompt and citation, clinician sign-off on the decision policy, regulator-ready model cards, and an appeals-friendly rationale on every decision.

"We went from 6-day median PA turnaround to 14 minutes for the in-policy 70%."

Outcomes you can underwrite

• 60–80% straight-through processing on in-policy cases.
• 10–30× faster median turnaround.
• 20–40% reduction in PA-related call volume.