Evry Health CEO and co-founder Chris Gay thinks the health insurance industry could eliminate prior authorizations entirely, but only if providers meet insurers halfway.
On the Becker’s Payer Issues podcast, he spoke about the technology and business model problems fueling prior auth friction, why state mandates might miss the mark, and why his organization joined dozens of other health plans this year in pledging to reform the process. Below is an excerpt from the conversation, which will air later this month.
Question: Evry Health has achieved a 7% prior authorization denial rate, with 100% of those denials upheld on appeal. What’s the biggest obstacle preventing larger insurers from replicating what you’ve built?
Chris Gay: It is a technology issue because of the scale. Prior authorizations are a shared frustration by both the medical provider community and the health plan side of the industry. But we have a job in population health to look across health systems, employers and state plans. When we do that at a large data level, you see a lot of variation in clinical care, and that impacts medical quality and patient experience.
Because it’s a big data problem, and because it involves a lot of complexity, it’s perfect for technology to solve. Let computers do the boring, challenging work of matching records, doing eligibility for patients, facilities, providers, and the code checks. That’s also why software is a superb solution, and why we’re happy to license what we do for other people.
Q: Is this also a business model problem?
CG: Absolutely. You’ve got organizations on the payer and provider side that are trying to maximize margin. And there are times to have margin. If you have no margin, you have no mission.
On the payer side, some organizations have expanded the number of codes that they put under prior authorization so they could take a little more time to evaluate and because too many things were getting pushed through that didn’t meet medical quality or standards.
On the provider side, you’ve got organizations that have contracted out their revenue cycle management and are not even directly talking to the health plan. That third party is oftentimes submitting for anything they can think of, and often resubmitting.
This is just a couple of examples of how both sides have weaponized against each other, and it’s fundamentally because the business models aren’t aligned around patient care.
That’s why AHIP has stepped forward on this. Fifty health plans, including Evry Health, are going to lead the industry on reducing the codes and enforcing more digital submission. We want patients to get an answer quickly, and we’re going to do this all based upon improving medical quality and patient experience.
Q: Many states passed prior authorization reform laws this year. Do you think voluntary, industry-wide commitments are a better path forward over a patchwork of state mandates?
CG: Speaking only for myself, I’m not a fan of patchwork state regulation because health plans, especially on the population health side, span multiple states, and it just creates system complexity. I’m more a fan of the voluntary initiatives that we were part of through AHIP that looks at this nationally.
Effectively, what they’re looking for is faster turnaround times and gold carding. I don’t think you need more legislation to get there. You can use technology and you can use voluntary commitments to improve the patient experience, to work with providers, and improve medical quality and lower costs. It’s all doable.
My organization’s goal is to go further. What if we could eliminate prior authorizations? What if we could gold card everything? That requires partnership with providers. We could get there as an industry, but there has to be accountability.
Q: CMS is rolling out the WISeR initiative in 2026, which will introduce prior authorization requirements for some services under traditional Medicare for the first time. Is this a step forward or backward?
CG: I don’t speak for the entire industry, but I think the administration is trying to take some of the lessons learned from Medicare Advantage and pull it over to Medicare. One of those is that sometimes you’ve got too much clinical variation that has a big impact financially, and they’re trying to reel that in a bit.
But it’s very early and too soon to grade them on their performance since they haven’t done any work yet. But I think it can be done very well. I personally don’t have a problem with using AI to do all the boring work that no clinician wants to do. This can be a decision support tool presented to nurses and doctors. As much as people are frustrated by Medicare all of a sudden having a potential due process to it, it may not be a bad thing.
I would say look at it in the bigger picture. Medicare Advantage was long term and originally meant to pull all the lessons from MA into Medicare. If you think of this on that long arc of 15 years of policy and planning, this is really just coming back to where we started. It’s not so radical.
