I wrote a long essay about the history of prior authorization. Not the talking points — the actual history. How we got from a reasonable idea in the 1960s to a $23 billion administrative apparatus that second-guesses every medical decision in America.
The full piece is on Substack: Prior Authorization; or, the Sixty-Year War Between Your Doctor and a Fax Machine.
Here’s why I wrote it, and what I think it means for where we go from here.
The short version
Prior authorization didn’t start as a villain. It started as managed care’s answer to a real problem: healthcare costs were rising, and someone needed to ask whether every procedure was genuinely necessary. The original intent — clinical appropriateness review — was defensible.
What happened over the next six decades was not.
The essay traces how a cost-control mechanism evolved into something unrecognizable: a system where insurance companies employ AI to deny claims at 16 times the normal rate, where physicians spend 13 hours per week on paperwork instead of patients, where 100% of surveyed oncologists report patient harm, and where the whole apparatus costs more to operate than it saves.
Why the history matters
Most conversations about prior authorization start with the current crisis — the denials, the delays, the burnout. But you can’t understand why the system is so resistant to change without understanding how it was built. Layer by layer, incentive by incentive, regulation by regulation.
The essay covers:
- The managed care origins in the 1960s and how utilization review became prior authorization
- The economic incentives that turned a clinical tool into a revenue protection mechanism
- The regulatory patchwork that makes reform so difficult — state by state, payer by payer
- The technology gap that left the system running on fax machines while everything else went digital
- The AI inflection point where insurers started using automation to scale denials rather than approvals
- The regulatory response including CMS-0057-F and state-level reform efforts
- What actually needs to change — and why technology alone isn’t enough
Why I’m writing this as a founder
I started Artificer Health because I believe technology can fix the operational layer of prior authorization — the submissions, the tracking, the appeals. And it can. That’s what we’re building.
But the deeper I get into this problem, the more I realize that the technical layer sits on top of a policy layer that’s fundamentally broken. You can automate a fax machine, but you can’t automate away a system that’s incentivized to say no.
The essay is my attempt to lay out the full picture — not just the part that technology can solve, but the part that requires policy change, regulatory action, and a fundamental rethinking of how payers and providers interact.
Read the full essay
Prior Authorization; or, the Sixty-Year War Between Your Doctor and a Fax Machine
It’s long. It has footnotes. I think it’s the most important thing I’ve written about this problem.
If you’re a physician, practice administrator, health system leader, or policymaker working on prior authorization reform, I’d love to hear what you think. Reach out at [email protected] or find me on LinkedIn.
Bobby Kuzma is the Founder & CEO of Artificer Health, where we’re building AI-powered prior authorization automation for physicians and medical practices. We’re currently recruiting pilot partners — learn more about the pilot program.