A physician submits a prior authorization request for a patient recovering from a cardiac procedure. A routine ECG is needed—standard follow-up care to monitor for arrhythmias that, if missed, can escalate quietly but quickly. She attaches the clinical notes, enters the diagnosis codes, and submits the request through the hospital system. To the physician, the task is complete. To the patient, care should now proceed.

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On the payer’s side, the same request arrives very differently. Key fields fail to align with the expected data structure. Clinical rationale is embedded in free text or locked inside a non-searchable PDF. Nothing is technically wrong, yet nothing can move forward. The request is not denied. It is not approved. It is paused—held in a digital waiting state created by two organizations operating on systems that were never built to communicate cleanly with one another.

This breakdown is often framed as a technical interoperability failure. In reality, it is also a product of how payer and provider systems evolved—and why.

Provider platforms were designed to support clinical documentation, coding, and reimbursement, often in the service of maximizing revenue in a fee-for-service environment. Payer platforms, by contrast, were built to manage utilization, control costs, and enforce policy compliance. These systems did not merely grow apart; they grew in opposition. Over time, mistrust became embedded not just in organizational culture, but in software design. Documentation is produced to justify care. Intake and review workflows are engineered to challenge it.

When clinical data arrives in formats that cannot be easily structured, validated, or reconciled with policy logic, the system’s safest response is to stop. Waiting becomes a risk-management mechanism.

The consequences are well known across the industry. Prior authorization requests flow through a patchwork of channels—faxed forms, PDFs, portals, phone calls, and partially electronic feeds—each using different formats and assumptions. Even when data is technically electronic, it is often not standardized enough to be trusted by default. Requests are returned not because care lacks medical necessity, but because the information cannot be confidently interpreted. Delays follow. Resubmissions increase. Clinicians absorb the burden through repeated follow-ups and after-hours administrative work, while patients experience uncertainty and deferred care.

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