From Friction to Foresight: How SamaCare Is Rewriting the Rules of Medical Benefit Prior Authorization

In an industry defined by complexity, few processes are as opaque, or as consequential, as medical benefit prior authorization.

In 2025 alone, SamaCare processed approximately $6.2 billion in buy-and-bill drug prior authorizations through its platform. That figure represents more than scale. It represents the largest real-world dataset on medical benefit drug access in the United States, spanning retina, oncology, neurology, rheumatology, and ambulatory infusion providers nationwide.

At this magnitude, patterns begin to surface. And what emerges is a sobering truth: prior authorization friction is not evenly distributed. Delays and denials cluster within specific payer–plan combinations, creating avoidable patient non-starts that market access teams often don’t see until months later, if they see them at all.

For Syam Palakurthy, CEO of SamaCare, operating at this scale reveals something fundamental about how access works in America.

“What operating at this scale reveals is that inconsistency and unpredictability are the rules — not by design, but by default,” Palakurthy says.

A System Built on Variability

Medical benefit access is not governed by a single set of rules. It is a highly complex system with multiple points of failure, and no single stakeholder, not the patient, not the provider, not even the payer, has full control or visibility.

Coverage variability is embedded at every level.

“Even two patients with the same insurer and plan can have very different journeys to treatment, caused, for example, by avoidable human error or process gaps which can lead to delays or denials without proactive mitigation,” Palakurthy explains, adding, “There’s a stark contrast between the human impact and how inhuman thise process is stark.”

On one side are patients, many with chronic, progressive, or life-threatening conditions, waiting for therapies their physicians have already determined are medically necessary. On the other side is an administrative process that dictates whether those therapies begin at all, and how long patients must wait.

Healthcare providers often serve as the primary access advocates, pushing prior authorizations forward so treatment can begin. But they are navigating a process that has grown exponentially more complex over the past decade.

Policies change frequently, often without formal notice. Coverage can vary by site of care, plan, state, and sometimes, if not in policy, then in practice, by time of year.

Manufacturers feel the downstream effects as well.

“They invest billions in R&D to bring life-saving therapies to market, yet often lose visibility in the last mile,” Palakurthy says. “They negotiate directly with payers, of course, but then an off-cycle policy change occurs, or a generic hits the market, or blizzard season hits, and all of the sudden patients are falling off treatment plans and they don’t know why. And if they don’t know why, they can’t help.”

Why No One Could See the Patterns

Despite prior authorization being one of the most significant barriers to timely specialty care, actionable insight has historically been elusive.

“The simple answer is that prior authorization has historically been so fragmented that no one has had real visibility—especially in real time—into what’s actually happening,” Palakurthy says.

Each payer operates differently, with distinct portals, forms, submission channels, documentation requirements, and response formats. Even approval decisions vary, covering different dosages, durations, and sites of care.

On the provider side, workflows have been equally fragmented. Many practices track authorizations through spreadsheets, sticky notes, or disconnected systems. There has been no standardized, structured way to generate consistent data across large networks.

Because both sides are fragmented, meaningful pattern recognition has been nearly impossible.

“To get any meaningful insight, SamaCare had to build a unified process that both standardizes how providers submit prior authorizations and allows those requests to be tracked across any payer, plan, and drug,” Palakurthy says.

That effort required structuring large volumes of previously unstructured data and simplifying countless submission pathways.

Before that kind of unified infrastructure existed, even electronic medical records and claims processors could not offer real-time visibility. They see downstream outcomes months later—without the nuance of the authorization journey itself.

Changing the Accountability Conversation

With more than $6.2 billion in authorizations processed in 2025, and nearly 2 million prior authorizations informing its AI, SamaCare now operates at a scale that reframes the accountability conversation.

“We see SamaCare as empowering frontline market access advocates—namely HCPs and pharmaceutical market access and patient services teams—to make prior authorization as frictionless as possible, at least from one end of the process,” Palakurthy says.

The company’s approach centers on standardization, automation, and intelligence layered into the submission workflow.

By eliminating human error and embedding insights learned from millions of authorizations, SamaCare helps identify not just what policies state—but what is implicitly enforced.

“We can learn what documentation is required, not just what policy states, but what is implicitly enforced,” Palakurthy says.

Once one side of the process is optimized, the system can clearly reveal what friction remains: where delays are occurring, where denials disproportionately affect specific patient cohorts, and where operational or policy changes may be needed.

“At the end of the day, for the patient (and the patient’s family) it’s not about who is accountable unless the process fails,” he says. “And when an administrative process like this fails, and a sick patient doesn’t get treatment, everyone in the system is accountable.”

Preventing Avoidable Patient Non-Starts

One of the most costly, and least visible, consequences of prior authorization friction is the patient non-start: when therapy never begins because the administrative process stalls.

SamaCare’s platform surfaces those risks earlier by reducing human error, eliminating information asymmetry, and establishing measurable benchmarks.

“Standardizing and automating the process reduces avoidable human mistakes,” Palakurthy says.

The system eliminates “wrong step” decisions, such as selecting the wrong submission method, that commonly lead to denials. It defines benchmarks for how long authorizations should take and escalates when friction appears.

“Human-in-the-loop AI continuously monitors the process and escalates the moment friction is detected—say, no response within 24 hours—so a delay doesn’t result in a rescheduled appointment or a patient churning,” he explains.

Policy monitoring is built into the platform, reducing denials triggered by recently updated requirements that practices may not yet know about.

Put together, automation addresses human error. Intelligence addresses wrong steps. Benchmarks create accountability. The result is more reliable treatment initiation, and fewer silent drop-offs.

AI With Humans at the Center

SamaCare combines artificial intelligence with human oversight, intentionally rejecting the “black box” model.

“SamaCare does not sell AI. SamaCare solves the problem of getting patients on their physician-prescribed treatments expediently—and helping them stay on those treatments—without the friction caused by medical benefit prior authorization. AI is an incredibly powerful tool to help us do that,” Palakurthy says.

The AI operates ambiently, learning continuously from tens of thousands of practices and SamaCare’s own prior authorization specialists.

“We’re never going to remove the humans,” he says. “Instead, we place humans where they have the highest impact—as managers and reviewers of the process, and as patient care strategists.”

When friction emerges, the system escalates to human specialists before delays become denials.

“PA specialists are teaching the system and learning from the system—and that’s what makes SamaCare better for everyone,” Palakurthy says.

Infusion Centers: A Growth Inflection Point

Adoption has accelerated rapidly among ambulatory infusion centers (AICs), where prior authorizations on the platform increased more than 70 percent year over year. SamaCare now supports 40% of the U.S. ambulatory infusion center market.

The trend reflects broader industry dynamics. AICs offer lower costs than hospital-based settings and greater flexibility for patients. They also serve a rapidly expanding specialty therapy population.

But infusion centers face unique complexity. They often manage multiple disease states, high therapy variation, and nuanced referral workflows that complicate authorization responsibility.

The financial stakes are substantial.

“For infusion centers, buy-and-bill therapies can represent up to 90% of operating costs,” Palakurthy says. “That makes obtaining authorization imperative—without a strong prior authorization management protocol, an AIC isn’t going to be in business for very long.”

Real-Time Market Access for Manufacturers

For life sciences companies, SamaCare’s scale provides both insight and action.

“Life sciences companies are using SamaCare’s data and in-workflow access to move market access from retrospective analysis to real-time action, with a direct focus on improving time to therapy,” Palakurthy says.

Manufacturers gain visibility into the gap between explicit payer policy and implicit enforcement. They can identify where providers consistently encounter friction and tailor education accordingly.

The platform enables both broad and targeted support, through sponsored messaging, enrollment callouts, and workflow-based nudges delivered directly within provider workflows.

Instead of learning months later that patients never started therapy, manufacturers can intervene while there is still time.

“We help brands run targeted interventions, measure their impact in near real time, adjust if needed, and then scale what works—before moving on to the next barrier,” Palakurt says.

Toward a More Predictable System

Looking ahead, Palakurthy believes prior authorization can become more predictable, but only if technology, regulation, and transparency advance together.

“We actively encourage and await regulation—particularly efforts like CMS-0057, which aims to standardize prior authorization on the payer side,” he says.

SamaCare abstracts payer complexity away from providers and partners, offering APIs used by other health tech platforms and EMRs to create more consistent infrastructure.

At the same time, the company aims to close longstanding information asymmetry gaps by analyzing millions of real-world decisions.

“By analyzing millions of real-world authorization decisions, SamaCare’s AI delivers clinical intelligence at scale,” Palakurthy says. “It doesn’t just automate forms—it learns which clinical evidence actually drives approvals, surfaces the right documentation automatically, and removes the guesswork that leads to delays and stalled care.”

For prior authorization to shift from unpredictable bottleneck to patient-centered process, industry stakeholders must move toward shared standards and greater transparency.

“When that happens, prior authorization can shift from an unpredictable bottleneck into a process that is more consistent, more accountable, and ultimately more centered on getting patients the care their physicians prescribe,” Palakurthy says.

In the meantime, scale, and the data it generates, offers something healthcare has long lacked in this arena: visibility.

And visibility is the first step toward change.

For more information, visit samacare.com.