Prior authorization remains one of the most persistent administrative burdens facing medical practices today — slowing patient access, straining staff, and draining revenue. In this episode of the MGMA Insights Podcast, Sr. Editor and host Daniel Williams sits down with Paola Ballester, MD, pediatric hospitalist, medical director for utilization management, and senior physician advisor at a major freestanding academic children’s hospital. She is also the co-founder of EasyPA, an AI-driven platform designed to modernize the entire prior authorization lifecycle.
A Clinical Leader with a Rare Lens Into Insurance Processes
Ballester’s perspective blends pediatric hospital medicine with years of hands-on experience in insurance operations — a combination that directly informs her approach to utilization management.
She explained, “I am a practicing pediatric hospitalist… and along the way, kind of got pulled into the utilization management and the revenue cycle management space.”
Her institution tapped her for this role because, before attending medical school, she spent several years as a claims adjuster. “I actually worked in the insurance industry for about four to five years,” she said.
That dual expertise allowed her to see what many clinicians cannot: the systemic misalignment between clinical intent and payer requirements. “Many physicians have no interest and really would rather do pretty much anything than deal with insurance companies,” she noted.
Her understanding of both sides has been critical in helping her organization “find better ways to do things” and support teams struggling with opaque authorization processes.
A Widespread Pain Point: Delays, Friction, and Staff Burnout
What pushed Ballester toward entrepreneurship was witnessing the same pain repeated across clinical teams: delays in care caused by incomplete submissions, unclear payer requirements, and the sheer volume of administrative back-and-forth.
She described watching “the countless delays going back and forth between the healthcare teams trying to submit clean claims… getting denied, having to do peer to peer phone calls… and then these back-and-forths, these delays, watching patients suffer.”
One case highlighted the scale of the problem. Ballester recounted what her team called the “220-minute case”: “We calculated about 220 minutes of time on paperwork and administrative burden… over a two month span, over 19 trail of emails, 14 members of four different teams… one failed peer to peer call, one failed denial and appeal.” For practices already stretched thin, that level of operational drag is not sustainable.
Why AI Is Emerging as a Tool for Managing Prior Authorization Complexity
For many organizations, the core PA challenge isn’t just workload — it’s the volume and variability of payer requirements. Authorization teams are expected to navigate shifting rules, documentation standards, and coding updates — often without centralized visibility. As Ballester explained, “We have such a mismatch of expertise in this realm of healthcare.”
Teams often rely on experience and best guesses, but the landscape is too dynamic for any single person to track in real time. “Even the most experienced practice manager… cannot possibly keep pace with the number of insurance policies… and the constant updates and payer requirements,” she said. This mismatch leads to preventable denials, rework, delayed care, and billing inefficiencies.
These realities are driving interest in AI-enabled tools that can support the administrative side of prior authorization. Ballester and her colleagues developed EasyPA as one such example — a platform designed to help practices interpret payer policies, identify missing documentation, and strengthen claims before submission. As described in the episode, AI-driven systems in this space can assist with functions such as:
- Identifying when a prior authorization is required
- Flagging incomplete or missing documentation
- Surface coding inconsistencies
- Assessing denial risk
- Supporting peer-to-peer preparation
- Drafting appeal materials based on payer policy language
- Assisting with post-bill denial review
The goal isn’t to replace human judgment but to reduce the administrative guesswork that drives delays. As Ballester put it, “Reducing denials because you’ve got a clean claim from the beginning is one of the most effective ways to improve your operations.”
Preparing for the 2027 CMS Prior Authorization Rule
Ballester urges leaders to act now, because major regulatory shifts are on the horizon.
She highlighted Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Final Rule (CMS-0057-F), noting that by January 1, 2027, all insurance companies are going to be required to be able to transmit prior authorizations electronically. In addition, payers will need to turn around non-urgent requests within seven days and provide more transparent reasoning for decisions.
This is a fundamental change. Right now, she warned, “less than 0.5% of practices are ready today.”
Organizations are still predominantly relying on fax machines, manual portals, and decentralized tracking risk falling behind once payers are required to modernize. “If your practice is still faxing and portal hopping… you're really missing out on an opportunity to decrease turnaround time for your patients,” she said.
Data: The Foundation for Choosing the Right Technology
With so many digital tools available, leaders often ask how to evaluate what’s worth investing in. For Ballester, the answer begins with visibility.
“Data is the most important thing,” she said. Many practices can't answer basic questions: How many authorizations are pending? What is the first-pass success rate? Which payers generate the most denials? “Blank stares,” she explained. Without operational clarity, transformation is impossible.
Understanding your workflow is equally essential. Drawing on lean methodology, she said leaders must “go to the Gemba” — the point where work actually happens.
“You’ve got to understand every touch point," she said. "You have to understand all of those pieces to really understand your opportunities.”
Leadership, Confidence, and Women in Healthcare Innovation
As a woman frequently navigating male-dominated spaces — both in clinical leadership and in tech entrepreneurship — Ballester shared candid advice for women in healthcare.
“I think a lot of times women, particularly and more so than men, have imposter syndrome and worry that they're not qualified, that they're not deserving of those opportunities," Ballester said, naming the internal hurdles many women face.
But her message to women leaders is both practical and affirming. “We deserve to be in the spaces just as much as anyone else,” she said. “I just challenge women to believe in themselves first and not to shy away from representing themselves, demanding their worth and their value and showing up in those spaces.”
Ballester also highlighted the positive impact of women clinicians, noting the growing body of evidence supporting gender diversity in medicine. “From everything on the clinical side, we know that many studies have shown better outcomes with female physicians, surgeons, and we are increasingly taking up and expanding in our leadership capabilities and roles.”
Her encouragement to other women: “Own that, be a part of that, and tell your story.”
Sustaining a Career Through Community and Boundaries
Outside her professional life, Ballester is a devoted basketball mom. She described her 13-year-old son as her motivation and grounding force: “He’s why I do everything that I do.”
Balancing clinical responsibilities, innovation work, and parenthood requires clarity and intention. As she put it, “You have to have your firm boundaries. What is important to you? What is non negotiable?” That commitment to protecting what matters allows her to stay grounded even amid demanding schedules and new ventures.
Her community — family, close friends, and fellow basketball parents — remains central to her ability to lead and to innovate. As she shared, “Those are the things that fill my cup and bring me a lot of joy outside of the daily kind of grind of medical practice and entrepreneurial life.”
