Prior Authorization Systems: A Critical Infrastructure Access Control Failure

A recent cluster of investigative reports across U.S. media outlets has exposed a fatal flaw not in medical technology, but in the digital and procedural systems that govern access to it. The case of a cancer patient—whose insurer repeatedly denied doctor-recommended, life-extending care, only to grant approval when it was tragically too late—is not merely a story of bureaucratic failure. For cybersecurity professionals, it is a stark case study in critical infrastructure access control failure, where authorization systems become the vulnerability that threatens human life.

The Authorization Layer as a Single Point of Failure

At its core, the prior authorization (PA) process is an access control mechanism. A physician (the user) requests access to a resource (a treatment, procedure, or medication) for a patient (the end-user/asset). The insurer (the system administrator) evaluates the request against a policy engine—a mix of automated rules, clinical guidelines, and manual review—before granting or denying access. This is conceptually identical to any Role-Based Access Control (RBAC) or policy-based access system in enterprise IT.

However, the investigation reveals this layer is profoundly broken. The failures are multifaceted:

1. Opaque Policy Engines: The criteria and algorithms used to make denial decisions are often proprietary and non-transparent. Doctors and patients cannot audit the 'rules' or effectively appeal because the logic is hidden. This is a fundamental violation of security principles like auditability and transparency.
2. Excessive Latency as a DoS Attack: The days or weeks spent in 'review' are not neutral. In fast-moving diseases like aggressive cancer, this latency is functionally equivalent to a Time-Based Denial-of-Service (DoS) attack. The system, through delay, renders the requested resource (timely treatment) ineffective or obsolete.
3. Lack of Fail-Safe or Override Protocols: Robust critical systems have break-glass procedures or manual overrides for emergencies. These healthcare authorization systems often lack streamlined, rapid escalation paths, leaving clinicians with no legitimate bypass when the automated system fails.
4. Inconsistent Policy Application: Similar cases receive different outcomes based on reviewer subjectivity, system errors, or inconsistent interpretation of guidelines. This unpredictability mirrors flawed access control lists (ACLs) where permissions are inconsistently applied.

Technical Parallels to Traditional Cybersecurity Failures

The parallels to known cybersecurity failures are striking. An insurance denial based on an opaque algorithm is akin to a false positive from a poorly tuned intrusion prevention system (IPS) that blocks legitimate business traffic. The procedural runaround faced by physicians—being passed between departments, asked for redundant information—mirrors the experience of a user trapped in an inefficient IT service management (ITSM) loop with no resolution.

Most critically, this represents a systemic design flaw where the security (or cost-control) mechanism itself becomes the primary threat to the availability and integrity of the core service: patient care. In cybersecurity terms, we would call this a vulnerability in the control plane.

The Human Impact: When Access Denials Become Fatal

The reported case crystallizes the risk. The patient's medical team identified a treatment with a clear potential benefit. The insurer's authorization system, acting as a gatekeeper, said 'no.' Appeals were filed—akin to submitting trouble tickets—and were denied. By the time human intervention or external pressure forced the system to grant the 'correct' permissions, the patient's condition had deteriorated beyond the point where the treatment could help. The access control failure was directly causal in the loss of life.

This moves the issue beyond IT inconvenience into the realm of critical infrastructure protection. If a power grid's SCADA system had an authorization flaw that prevented operators from responding to a cascade failure, it would be a national security incident. Healthcare authorization systems control access to life-sustaining resources with similar consequence.

A Call to Action for the Security Community

Cybersecurity professionals must expand their view of critical infrastructure to include these administrative and financial transaction systems that sit atop medical technology. The lessons from securing industrial control systems (ICS) and operational technology (OT) are relevant:

• Resilience Over Mere Compliance: Systems must be designed to fail safely and allow legitimate critical actions to proceed, even if under heightened scrutiny or manual review.
• Transparency and Auditability: The decision logic of automated authorization engines must be subject to independent review and challenge. Patients and providers have a right to a clear 'denial reason' that can be technically and medically contested.
• Performance SLAs as a Security Metric: Authorization systems must have strict, legally binding service level agreements (SLAs) for response times, especially for urgent care. A 72-hour review cycle is a vulnerability for a patient with septic shock or progressing cancer.
• Redundancy and Escalation Pathways: Just as critical networks have redundant links, authorization workflows need mandated, rapid escalation paths to human experts with the authority to override automated denials.

Conclusion: Reframing the Threat Model

The tragedy highlighted by these reports is not an isolated medical billing error. It is a symptom of a deeply flawed authorization architecture within a critical sector. For too long, cybersecurity in healthcare has focused on protecting patient data (CIA triad: Confidentiality) and ensuring medical device safety (Integrity). This case demands we give equal weight to Availability—ensuring that patients and their caregivers can reliably access the care they are entitled to, without being blocked by dysfunctional digital gatekeepers.

The threat model must now include the insurance and payment adjudication systems as part of the healthcare attack surface. Their failure modes—whether from flawed design, intentional cost-saving policies that mimic malicious denial-of-service, or simple incompetence—can have kinetic, real-world consequences as severe as any ransomware attack on a hospital. Securing these systems is not just about finance; it is a fundamental matter of human safety.