Faisal Zain, a seasoned expert in medical technology and health information systems, joins us to pull back the curtain on one of the most contentious areas of modern medicine: prior authorization. With an extensive background in the manufacturing and innovation of diagnostic and treatment devices, Faisal understands the friction points where technology meets patient care. He brings a grounded, perhaps even provocative, perspective to the table, challenging the corporate “theater” often seen at health tech conferences. Our conversation explores the structural imbalances between payers and providers, the reality of the AI “arms race,” and the critical need for a clinical record that finally tells the patient’s true story.
This interview explores the fundamental power struggle at the heart of prior authorization, where financial interests and clinical needs often collide in a high-stakes environment. We discuss the “asymmetry of speed” that allows payers to deny care in milliseconds while providers spend weeks on appeals, the staggering human cost reflected in delayed treatments and adverse events, and the potential for AI to either industrialize this imbalance or finally solve the evidence problem. Faisal argues that the future of healthcare depends not on forced collaboration, but on creating an auditable, evidence-based system that places the patient’s actual clinical reality at the center of every decision.
Payers often process authorizations much faster than providers can appeal them. How does this technological asymmetry redefine the struggle between those paying for care and those providing it?
The reality is that we are witnessing the industrialization of an imbalance that has existed for thirty years. Large national health plans have the capital and the data to process more prior authorization decisions in a single week than a typical health system encounters in an entire year. This allows them to deploy algorithms that can generate a defensible-looking denial in mere milliseconds, essentially automating the rejection of care. On the other hand, the provider is left with an archaic system where an appeal can take thirty days of manual labor, phone calls, and paperwork. This isn’t just a lag in time; it is a structural barrier that allows the speed of denial to outpace the human capacity for recourse, leaving the patient caught in a gap where their health is the only thing moving slowly.
With sixty percent of physicians expecting AI to actually increase prior authorization denials, why is the industry still pushing a narrative of “collaborative care ecosystems”?
That narrative is largely theater designed to reassure stakeholders and sell software that doesn’t solve the underlying conflict. If you sit at any major health tech conference, you’ll hear executives use words like “alignment” and “partnership,” but those interests simply do not align—one side wants to control spending while the other wants to deliver care and get paid. The American Medical Association’s data is a sobering wake-up call, showing that the people on the front lines see AI not as a bridge, but as a more efficient way to close the door on treatments. We have to stop pretending that software will magically turn these adversarial parties into partners holding hands; instead, we need to acknowledge that they are in an arms race where the side with more data and faster processing power currently holds the high ground.
How does the current state of prior authorization impact the physical and emotional well-being of both patients and their doctors?
The human cost of this system is staggering and deeply personal, often described in clinical literature as a form of “moral injury” for healthcare workers who feel prevented from doing what is right for their patients. When you look at the statistics, more than one in four physicians report that the prior authorization process has led to a serious adverse event for a patient under their care. Beyond the physical risks, there is the sheer exhaustion of navigating a system where ninety-five percent of doctors report care delays as a standard part of the process. For the patient, there is no AI to help them; they are left with a phone tree, a high deductible, and a disease, waiting for a resolution while their health potentially declines in real-time.
If the core of the fight is about evidence, why has it been so difficult to create a shared, structured clinical record that both sides can agree on?
The difficulty lies in the fact that, currently, both sides are arguing from completely different, partial sets of information. The payer is looking at claims data and policy documents, while the provider is looking at labs, imaging, and the person sitting in front of them in the exam room. Often, the crucial evidence needed to approve a treatment is buried deep within three different PDFs or a poorly scanned fax that the payer’s system can’t easily digest. One in three physicians says that the criteria used for these authorizations are rarely or never even based on evidence. This lack of a clean, complete, and structured view of what actually happened to the patient means that the side with more resources and leverage—usually the payer—wins by default because the record is too fragmented to settle the argument.
What specific changes should regulators implement to move away from “AI-driven harmony” and toward actual transparency and accountability?
Regulators need to stop being seduced by the vague promises of AI harmony and start demanding real, auditable transparency. Every single prior authorization decision made by an algorithm should be required to carry its specific reasoning, the evidence used, and the policy citation in a format that can be audited at scale. If a health plan’s AI is generating a high volume of denials that systematically disappear or are overturned once an independent reviewer looks at them, there should be financial and legal consequences proportional to that volume. We need to move toward a system of contested, evidence-based adjudication where the software serves as a tool for clarity rather than a shield for arbitrary cost-cutting.
Instead of trying to “beat” payer AI with their own automation, what is the most effective move for healthcare providers to make right now?
The winning move for providers isn’t finding a “faster fax” or buying a tool that promises to outsmart the payer’s algorithm; it is investing in a clinical data infrastructure that makes their case undeniable from the start. We need to build records that are so complete and so structured that the argument is over before it even begins for the cases that should never have been contested in the first place. When a payer claims a patient didn’t fail a prior therapy, or when they demand proof of disease progression, the clinical record should be able to produce that data instantly and indisputably. By focusing on the integrity and accessibility of the patient’s story, providers can force the fight to happen on the merits of the care rather than on the gaps in the paperwork.
What is your forecast for the future of prior authorization?
My forecast is that the “kumbaya” version of healthcare collaboration will continue to fade as the reality of an adversarial AI arms race becomes impossible to ignore. We are moving toward a future that is more contested, but hopefully more auditable, where the speed of software is finally matched by the speed of truth. I expect to see a significant shift in the next few years where the clinical record becomes the ultimate “referee,” and those who cannot provide a structured, evidence-based account of patient care will find themselves losing ground. Ultimately, the system will remain a fight, but it will be a fight conducted on shared evidence, with a clock and a referee, ensuring that the patient’s actual clinical reality is finally the most important factor in the room.
