The insurance industry is a growing component in our society and plays a role in many different parts of our lives. Especially as technology continues to advance at a rapid pace, it is important that these vital industries are able to adapt to keep up. However, there are still several processes within insurance processing that are outdated given today’s innovation.
Prior authorization is a process that helps to guide insurance companies in determining whether or not to cover a procedure, service, or medication. This process was originally designed to protect resources and save money, and can help to ensure that patients get the care they need in a timely manner. However, studies are now showing that 1 in 3 US providers say prior authorization processing delays have led to an adverse event for patients. Because of this, experts are in search of a way to ease this burden and improve the overall approval process.
There are several other unintentional side effects to poor prior authorization. First, physicians end up paying extra for medical staff, and there are higher costs incurred with the ineffective traditional methods. Additionally, there is an increased administrative burden on physicians under current prior authorization processes. For patients, prior authorization most commonly leads to delays in access to care. However, it can also lead to hospitalization, life-threatening events, or even disability or permanent bodily damage. Both patients and providers have expressed concern about these disturbing new trends, driving forward the need for innovation.
Understanding Prior Authorization
The current process of submitting prior authorization is manual, requiring human expertise to complete. This process begins with manually checking a patient’s insurance details, then manually reading any medical charts or clinical documents. After scanning this information, a PA request is then manually submitted via Fax or a payment portal. This step of the process can take up to 15-20 minutes per patient. There is then a need for a follow up with the provider to check the status of the prior authorization being submitted. This step requires several phone calls, emails, and often frequent logins to the payer’s portals. Then, if the authorization is denied or additional information is requested, the staff must prepare documentation or submit an appeal letter. Once this is resubmitted, the original steps must be repeated until an approval is earned. Once the authorization is accepted, the staff must then manually update the system, add any approval documents, and clarify case status before rendering any patient care.
Manual prior authorization is much more time-consuming and is prone to error due to human intervention. Because of the tedious nature of this process, experts are working towards developing and implementing a new AI-backed prior authorization process automation method for prior authorization approval.
Benefits of AI-Powered Prior Authorization
An automated method for prior authorization would use artificial intelligence to drive a number of helpful features that have previously been impossible under the traditional manual method. First, artificial intelligence can retrieve required patient information and make calls to payers. This speeds up the process, allowing for providers to complete the necessary notes and documents in a timely manner. AI can read documents and validate the required information. It determines if a patient meets prior authorization guidelines. AI then prepares the PA request and submits it through the portal. It identifies the status of the request and takes steps to resolve any issues. Once the final decision is received, AI updates patient records with the new status and documents automatically.
The Future of Prior Authorization
AI-powered solutions, although still early in development, are already solving prior authorization challenges. First, electronic prior authorization strategies represent $449 million in cost savings for the US medical industry alone. Also, artificial intelligence has the power to manage 1.3 million rules used by over 300 health plans, ensuring that all cases can be handled by this technology. In addition to cost savings, automated prior authorization can improve patient experience, streamline workflows, and lead to more efficiency. Improved accuracy, lower costs, and faster turnaround times highlight the impact of these technological breakthroughs. Organizations across the country can save time, money, and resources. At the same time, they can better serve their patients using AI-backed prior authorization methods.
Source: Orbit Healthcare
