Bain · Tech Consulting · Hard · 35-45 min

US Health Insurer Automating Prior Authorization

US Health Insurer Automating Prior Authorization is a hard Bain tech consulting case interview that runs 35-45 min. A US national payer covers 6.2M commercial and Medicare Advantage members. A strong answer works through 5 phases: Segment requests; Build the value bridge: cost per request, days-to-decision, appeal and overturn cost, provider abrasion; Design the decision path; Map the CMS obligation: FHIR prior-auth API, decision clocks, and what 'impacted payer' lines are in scope first; Recommend a phased auto-adjudication target with the clinical governance that makes 60% defensible.

Last updated 2026-09-05

The brief

A US national payer covers 6.2M commercial and Medicare Advantage members. Prior authorization still runs through fax, portal, and phone: 11M requests a year, about $16 fully loaded per manual request, median decision time 6 days. CMS-0057-F pushes impacted payers toward FHIR APIs and shorter clocks (72 hours urgent, 7 calendar days standard). Overturned denials are 18% on appeal and member NPS on the auth journey is −12. The COO wants 60% of requests auto-adjudicated in 18 months. Clinical leaders will not sign a model that denies care. You are advising the CEO on whether 60% is real and how to get the CMS clock without a lawsuit.

How to approach it

  1. Segment requests — gold-card / low-variance procedures vs clinical judgment vs documentation-only — before quoting an automation rate
  2. Build the value bridge: cost per request, days-to-decision, appeal and overturn cost, provider abrasion
  3. Design the decision path — rules, then retrieval over the policy, then clinician — and where a model is forbidden to deny
  4. Map the CMS obligation: FHIR prior-auth API, decision clocks, and what 'impacted payer' lines are in scope first
  5. Recommend a phased auto-adjudication target with the clinical governance that makes 60% defensible

What a strong answer does

  • Refuses a flat 60% and rebuilds it from request classes that are safe to auto-approve
  • Keeps denial authority with a clinician and uses automation to approve and to assemble the file
  • Connects the CMS clock to an operating change, not only an API project
  • Tracks overturn rate and provider NPS next to unit cost
  • Sequences Medicare Advantage or a narrow procedure set before the whole book

Red flags interviewers score down

  • Lets a model deny care with no clinician and no appeal design
  • Treats CMS-0057 as a portal upgrade
  • Counts gross FTE savings and ignores appeal cost and clinical review that remains
  • Promises 60% in month six with no gold-card or policy-encoding plan

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