The Evolution of Prior Authorizations

In the ever-shifting terrain of healthcare, where innovations and challenges coalesce, there is a constant pursuit of improvement. Whether addressing evolving technological needs or streamlining administrative processes, there will always be areas to refine and enhance to help drive safer, more holistic care delivery models.

Throughout my career, I’ve had the privilege of collaborating with visionary leaders committed to driving positive changes in healthcare. In 2005, I began work on an innovative idea aimed at solving prior authorizations by scaling the manual process within the utilization management workflow. This pivotal moment marked the beginning of my journey toward addressing and improving healthcare inefficiencies.

The concept of prior authorizations originated from a need to ensure appropriate and cost-effective utilization of healthcare resources. During the early stages of outpatient prior authorization adoption, utilization management nurses and physicians from health plans or delegated organizations —armed with yellow pads due to the unreliability of systems—would have back-and-forth conversations with providers to exchange clinical information with the objective of determining the medical necessity of certain treatments, procedures, or medications.

Although this human-centric approach serves as an effective check and balance, it’s still a labor-intensive process. At times, this process can take anywhere from two business days to several weeks, depending on the intricacy of the medical case, in order to assess the medical necessity of a treatment. This time-consuming endeavor diverts crucial resources from patient-focused tasks, as dedicated personnel spend significant hours communicating with payers to clarify information, answer queries, and ensure all necessary documentation is provided.

Over the years, technological advancements, including the integration of attestation questions and web portals, have brought substantial improvements to the prior authorization process. However, the shift from nurse-led discussions to non-clinical, machine interfaces raise concerns about the loss of the personal, clinical touch. Despite its acknowledged role as a check and balance in utilization management, the industry grapples with the drawbacks of this increasingly impersonal system, as of 2023.

Bringing the Clinical Interaction Back into Prior Authorizations with Artificial Intelligence (AI) and Natural Language Processing (NLP)

In the quest to restore the vital element of clinical interaction to the prior authorization process, AI and NLP emerge as powerful tools. AI can be taught to understand evidence-based literature and a health plan’s guidelines to streamline the most critical touchpoint: determination of medical necessity. In addition, with enhanced interoperability we now have the capability to incorporate and exchange clinical information instead of just nonclinical data within the system. This lays the groundwork for establishing a clinical intelligence platform that empowers healthcare organizations to make decisions grounded in clinical data, fostering deeper insights from the information available. 

Unlike other solutions in the market that rely on statistical modeling based on historical data, Availity AuthAI harnesses the power of AI, NLP, and clinical data. Developed and refined over several years, this proprietary utilization management engine delivers speed and accuracy to medical necessity reviews for providers and near real-time decisions at the point of care for patients. As the nation’s largest health information network, Availity facilitates over 11 billion clinical, administrative, and financial transactions annually.  The ability to provide real-time status updates and auth administration within the Availity Essentials and Essentials Pro workflows facilitates automation for a touchless authorization experience at scale.

The seamless integration of Availity AuthAI within the nation’s largest health information network not only underscores its technological prowess but also translates into impressive real-world outcomes, as demonstrated by a recent successful implementation by a payer for three major programs. Constituting 80 percent of the organization’s authorizations, the system efficiently manages 4,000 cases daily, with an impressive 78 percent being resolved without human intervention. The remaining 22 percent of authorizations are addressed by human involvement. The entire process, from submission to authorization, achieves a median response and resolution time of just 27 seconds.

In contrast to the previous average turnaround time of 2.5 days, the current timeframe is reduced to a matter of hours. This improvement includes cases that necessitate manual handling. Remarkably, the daily handling of 4,000 authorizations now requires only a fraction of the resources compared to the previous requirements.

To learn more about Availity AuthAI’s distinctive approach to ensuring superior accuracy, precision, and consistency in care delivery decisions, visit us here. 

About the Author

Matt Cunningham, Executive Vice President of Product at Availity, brings a unique background with nine years of military service, including command roles during the Iraq invasion and subsequent counterinsurgency operations. Transitioning to healthcare, he has spent over 15 years addressing challenges in prior authorizations and utilization management. With a diverse career, Matt played pivotal roles in scaling a services company from $20M to the largest healthcare benefit services firm, serving in capacities such as Head of Call Center Operations, Director of Product Operations, CIO, and leading integration for mergers and acquisitions. In his latest role, he spearheaded innovation efforts automating prior authorization workflows. Matt also serves as President of the Vantage Point Foundation, dedicated to aiding post-9/11 veterans and their families in transitioning to civilian life.