Anterior's Approach to Fairness Evaluation of Automated Prior Authorization System

Prior authorization remains one of the most burdensome administrative processes in U.S. healthcare, consuming billions of dollars and thousands of physician hours each year. While large language models have shown promise across clinical text tasks, their ability to produce submission-ready prior authorization letters has received only limited attention, with existing work confined to single-case demonstrations rather than structured multi-scenario evaluation. We assessed three commercially available LLMs (GPT-4o, Claude Sonnet 4.5, and Gemini 2.5 Pro) across 45 physician-validated synthetic scenarios spanning rheumatology, psychiatry, oncology, cardiology, and orthopedics. All three models generated letters with strong clinical content: accurate diagnoses, well-structured medical necessity arguments, and thorough step therapy documentation. However, a secondary analysis of real-world administrative requirements revealed consistent gaps that clinical scoring alone did not capture, including absent billing codes, missing authorization duration requests, and inadequate follow-up plans. These findings reframe the question: the challenge for clinical deployment is not whether LLMs can write clinically adequate letters, but whether the systems built around them can supply the administrative precision that payer workflows require.

Public institutions increasingly procure AI systems whose design they cannot inspect or change. In higher education, proprietary Early Warning Systems (EWS) leave colleges with few options beyond adjusting model outputs to address inequity. This raises the question of how fairness work is coordinated among vendors, institutions, advisors, and students with unequal power to change these systems? Using student records from a public college in Ontario, Canada, we evaluate six post-hoc fairness interventions on a research EWS under simulated procurement constraints. We compare fairness, accuracy, and demographic disparities, introducing error-type profiling to trace how interventions redistribute false positives and false negatives. Interventions redistributed disparities without consistently reducing them. Two implementations favored already-advantaged groups because they used group size to define disadvantage; small, marginalized groups remained poorly served. These findings show how procurement constraints and implementation choices shape the possibilities for fairness work. We call the resulting condition fairness theatre; dashboard metrics converge while groups' error burdens persist or worsen.

The evaluation of fairness in machine learning systems has become a central concern in high-stakes applications, including biometric recognition, healthcare decision-making, and automated risk assessment. Existing approaches typically rely on a small number of fairness metrics to assess model behaviour across group partitions, implicitly assuming that these metrics provide consistent and reliable conclusions. However, different fairness metrics capture distinct statistical properties of model performance and may therefore produce conflicting assessments when applied to the same system. In this work, we investigate the consistency of fairness evaluation by conducting a systematic multi-metric analysis of demographic bias in machine learning models. Using face recognition as a controlled experimental setting, we evaluate model performance across multiple group partitions under a range of commonly used fairness metrics, including error-rate disparities and performance-based measures. Our results demonstrate that fairness assessments can vary significantly depending on the choice of metrics, leading to contradictory conclusions regarding model bias. To quantify this phenomenon, we introduce the Fairness Disagreement Index (FDI), a measure designed to capture the degree of inconsistency across fairness metrics. We further show that disagreement remains high across thresholds and model configurations. These findings highlight a critical limitation in current fairness evaluation practices and suggest that single-metric reporting is insufficient for reliable bias assessment.