Automation in Medicaid Prior Authorization

Chapter 2 focuses on automation in Medicaid prior authorization (PA). MACPAC has looked at how payers and providers are increasingly incorporating technology, including artificial intelligence (AI), to automate parts of the Medicaid PA process. Automated systems that use algorithms or AI to conduct portions of the PA process have the potential to reduce burdens associated with PA and promote appropriate, cost-effective care. However, automated PA processes present potential risks to beneficiaries, states, providers, and health plans, and there is limited transparency into how these tools make decisions. In addition, there is little federal guidance on these tools, and state guidance varies. MACPAC makes recommendations to address the risks posed by automation tools, strengthen oversight, and increase disclosure and transparency of managed care plans’ use of automation in PA.