Transforming Prior Authorizations with AI-Powered Automation

Prior authorizations help to manage healthcare costs by confirming the necessity of procedures, treatments, and medications recommended by providers. However, the process is largely manual, burdensome and can cause delays in patient care. In fact, an American Medical Association study found that 94% of patients experienced delays in care, 80% of providers said that authorization problems could cause patients to stop treatment, and about one-third of providers reported negative health outcomes because of delays with prior authorizations. Yet, the underlying cause of frustration is not the prior authorization itself, but the manual process supporting it.

Electronic prior authorizations have the potential to save organizations around $450 million annually, however use in the healthcare industry is still very limited because these transactions are a series of complex conversations between payers and providers. While necessary, the conversations required to gather vital clinical information can often lead to provider abrasion, delayed treatment, and operational inefficiencies. These challenges include increased administrative burden, reimbursement issues, and difficulties in managing patient expectations within coverage constraints.

Accelerating Prior Authorization Reviews with AI-Powered Automation

Improving the prior authorization review process requires healthcare industry stakeholders to understand its complexities. It is important to create a system that focuses on standardization, and the seamless integration of artificial intelligence (AI). This system should combine administrative and clinical data to make the authorization workflow more efficient. When patient information and orders adhere to consistent and compatible formats, it becomes simpler to exchange and understand data across various systems.

Additionally, integrating AI into the end-to-end authorization process brings several advantages. AI can interpret clinical data quickly and accurately, helping to match patient information to a health plan’s medical policy. This helps to improve decision-making and allows for more informed assessments during the authorization review process. Automating the repetitive tasks of the review process and leveraging deep learning techniques improves efficiency, reduces manual errors, and ultimately accelerates the entire utilization management workflow.

The key is to use automation for processes that are already well-coordinated among payers and providers. For example, payers can reduce unnecessary calls related to authorizations by ensuring providers have crucial information earlier in the process. This includes:

• Providing a central place for submitting and managing documents.
• Checking if an authorization or medical attachment is required.
• Stating if a delegated vendor handles the authorization.

Another challenge AI-powered automation helps solve within the prior authorization process is the need for providing medical documentation for clinical review. Currently, providers invest significant time in clarifying information and responding to queries to meet payer requirements for determining the medical necessity of treatments. These manual tasks are time-consuming, costly, and frustrating for providers. By adopting a user-friendly, AI-powered system, health plans and providers can streamline the digital exchange of information, offering an efficient and effective alternative to manual processes. Allowing medical staff can spend less time on manual processes and more time focusing on what they do best—providing quality care to those they serve.

The Importance of Responsible AI

Responsible AI is crucial in addressing prior authorization challenges, particularly in determining medical necessity. Availity AuthAI™ prioritizes transparency, blending AI with human clinician expertise. The Availity AuthAI system undergoes thorough validation by health plan clinical staff during implementation and continuous monitoring during delivery. Additionally, the submitter is presented with all of the AI suggested answers to attestation questions to ensure accurate representation of the provider request. Unlike a black-box approach, Availity AuthAI offers recommendations instead of absolute decisions. This approach ensures that we maintain an ethical stance for accuracy, mitigating the risk of adverse outcomes, and enabling thorough review processes.

By training AI to understand health plan policies and assess cases based on clinical information, we move away from biased regression models. This ensures a transparent, auditable decision-making process. The potential impact is significant, automating approvals in about 80% of cases. Automation allows human intelligence to focus on the 20% percent of cases that require more thorough review.

Why Choose Availity

As the nation’s largest health information network, Availity believes widespread adoption of electronic standards and automation will cut administrative burdens, lower care costs, and enhance patient outcomes. Our products and services are designed to acquire, enrich, and exchange clinical, administrative, and financial health data in ways that are automated, compliant with national standards, consistent with its original intent, and refined for broad-scale application and actionable intelligence.

Availity processes more than 13 billion electronic transactions a year across thousands of payers and millions of providers. Additionally, Availity has served as an active collaborator with industry organizations, including Health Level Seven International (HL7) DaVinci Project, the Workgroup for Electronic Data Interchange (WEDI), ASC X12, and the Cooperative Exchange to advance standards in data usability and exchange. Our suite of solutions creates a comprehensive, end-to-end authorization platform that streamlines the critical functions of the authorization process and empowers providers and payers to manage prior authorizations more effectively.

Click here to learn more about how Availity AuthAI leverages AI, natural language processing (NLP) and clinical data to provide authorization reviews in seconds.

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.