Creating a Direct Connection Between Payers and Providers Through AI

Despite efforts to ensure appropriate and cost-effective utilization of healthcare resources, the prior authorization process continues to wreak havoc on operational workflows. Health plans face strain due to the significant administrative workload involved in reviewing and approving requests. Providers are burdened by the manual process of submitting prior authorizations, and members are impacted by the time spent waiting for approval. The collective acknowledgement that the prior authorization review process needs improvement has fostered collaboration among stakeholders across the industry.

During a recent presentation at ViVE, I sat down with Steven Kos, MSHCA, Sr. Director of Revenue Cycle Applications at Baptist Health, and Jay Sandhaus, CTO of Rhyme, to discuss the collaboration between Baptist Health, Rhyme, and Availity^® to launch an AI-powered prior authorization review tool with the goal of automating manual processes and enhancing operational efficiencies. To watch the full panel discussion, please click HERE.

In this blog, I’ll outline our panel discussion, spotlighting the operational hurdles encountered by Baptist Health in its revenue cycle, Rhyme’s systematic approach to addressing these challenges, and Availity’s AI-powered authorization review tool to provide data-driven decisions at the point of care. This unified partnership serves as a compelling example of how effective collaboration within the healthcare sector can positively impact payer and provider workflows, but most importantly patient care.

Identifying Prior Authorizations as a Key Workflow for Reducing Administrative Burden

For Baptist Health, its focus was enhancing operational efficiency across the revenue cycle. They conducted an assessment to determine where internal automation through its electronic health record (EHR) could be optimized. Among the top priorities, prior authorization emerged as a critical area of opportunity to substantially reduce administrative burden. This is due to the manual tasks involved with logging into multiple portals and navigating the various requirements of prior authorizations.

Providers often spend time repeatedly checking for status updates, supplying additional information, and sometimes resorting to phone calls for clarification. On average, physicians dedicate two business days each week to these time-consuming tasks¹, diverting crucial resources from patient-focused activities. Faster turnaround times for authorizations are essential to improving the revenue cycle and ensuring patients receive timely care and the attention they deserve.

Taking a Systematic Approach to Bridge the Gap Between Payers and Providers

During the presentation, Jay emphasized that the challenges faced by Baptist Health are widespread across the healthcare industry, affecting large and small hospital systems, as well as individual providers. This critical process of financial pre-clearance involves extensive exchange and harmonization of information between payers and providers. It’s not just a matter of communication between one provider and one payer, such as Baptist Health and Florida Blue. Rather, it involves numerous individuals within a system like Baptist Health, each generating different information based on their practices.

Similarly, on the payer side, the decision-making process involves multiple internal and external systems to determine coverage and whether prior authorization is necessary for specific services. Rhyme recognized the complexity of this issue and sought a systematic approach to address it. Their goal was to bridge the gap between payers and providers perspectives in a reproducible, efficient manner, allowing them to collaborate effectively to expedite patient care.

Taking a systematic approach involved identifying key variables to be addressed, including reducing administrative burden and streamlining the prior authorization process to minimize human effort. The manual nature of current processes involving copying and transcribing information from electronic medical records presents a significant obstacle to timely patient care. By tackling these challenges systematically, the aim is to facilitate quicker access to care for patients.

Creating a Direct Connection Between Payers and Providers Through AI

For Baptist Health, it was crucial to remain within the Epic EHR system to minimize disruptions. Transitioning between systems can introduce friction, leading users to revert to familiar methods. Therefore, Rhyme’s approach began within Epic.

Providers initiate the order within Epic, which seamlessly transfers to Rhyme. In most cases submission is touchless, but if information is incomplete or erroneous, Rhyme launches a UI to fix that data via a deep link directly from Epic. Rhyme helps gather and submit clinical documentation, as they’ve observed significantly higher approval rates when this documentation is provided up front.

Once the clinical documentation is uploaded, Rhyme interfaces with Availity using Availity’s robust suite of APIs for authorizations. Here, Availity’s AI technology comes into play by leveraging payer medical policies and presenting clinical attestation questions that prompt submitters to provide necessary information, while analyzing the uploaded clinical documentation. Unlike generative AI, Availity’s approach involves comparing and evaluating data side by side to make informed recommendations to payers.

Once the recommendation is generated, it’s forwarded to the payer, completing the cycle. At this point, the Baptist team can view the status directly at the point of care. With an impressive 80% approval rate, many cases receive first time approval within 90 seconds. This streamlined process facilitates prompt scheduling leading to better compliance with patient care protocols.

Overall Results

After integrating the tool for diagnostic imaging, Baptist Health utilized a reporting tool to assess the productivity gains achieved through automation. Remarkably, they successfully met all the objectives they had set out to accomplish with the solution.

• Reduced Manual Intervention: By focusing on undiagnostic imaging, Baptist Health significantly reduced the need for manual review. Out of approximately 1,800 cases within a 30-day period, only around 850 to 900 cases required manual intervention, marking a substantial reduction in volume. 
• Reduced Administrative Burden and Costs: The implementation led to the elimination of three full-time equivalent positions and a reduction in annual overtime costs. Simplifying the process streamlined education and enhanced understanding among staff, resulting in more efficient workflows. 
• Increased Provider Satisfaction: The streamlined process improved intuition for end users, enhancing their ability to address issues promptly. Utilizing dashboards facilitated monitoring productivity across various processes. 
• More Time for Patient Care: Shifting resources towards patient care was a priority. Turnaround time for prior authorization decisions improved significantly, enabling a shift from concerns about authorization to scheduling appointments with confidence.

These impactful changes occurred within a matter of months, requiring minimal IT effort for the initial iteration focused on diagnostic imaging. The projected 90-hour effort aligned closely with the actual time spent on the project by Baptist Health. In addition, the integration process smoothly embeds itself into the existing provider workflow, causing minimal disruption to daily operations. This seamless transition allows providers to swiftly proceed with downstream activities such as scheduling and care delivery. Beyond the benefits of speed and automation, this process provides comprehensive transparency into each authorization from start to finish.

If you’re interested in learning more about Availity AuthAI™, please visit us here. 

About the Author

Shari Matkin, Director of Technical Implementation at Availity, is a seasoned and customer-centric business and technical leader. With extensive expertise in directing all aspects of healthcare IT, digital transformation, and technology commercialization, Shari excels in enhancing customer experience within the healthcare industry. 

A forward-thinking leader with both tactical and strategic vision, Shari maintains a keen bottom-line focus, achieving verifiable success in maximizing efficiency and results through the delivery of value-added services. Shari’s track record includes remarkable achievements in building and leading high-performing teams, overseeing large-scale projects, and delivering intricate healthcare data integrations to customers. Shari consistently exceeds client expectations and resolves business challenges through technology, optimizing business performance and ensuring exceptional client satisfaction in healthcare IT delivery.