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8 min read


HOW TO LEVERAGE AI-ENABLED AUTOMATION TO SOLVE BIGGEST CHALLENGES IN PRIOR
AUTHORIZATION

 * Healthcare
 * Artificial Intelligence
 * Innovation

Feb 14, 2024
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In the complex, rapidly evolving landscape of healthcare, the prior
authorization (PA) process emerges as a critical yet challenging checkpoint.
This activity,  essential for verifying coverage for treatments, medications, or
equipment before they are provided to patients, stands at the heart of cost
control and the delivery of appropriate care. Yet, its traditional management is
wrangled with inefficiencies that cause delays, increase costs, and frustrate
both providers and patients. In fact, 93% of healthcare providers report care
delays while waiting for insurers to authorize necessary care with 82%
highlighting that authorization can lead to treatment abandonment because of
prior authorization struggles with their insurance company.

These  inefficiencies are contribute to the estimated $950B spend on
administrative functions and are a source of frustration for healthcare payers,
providers and patients alike.

Recent advancements in technology, however,  have stirred heightened interest
around artificial intelligence (AI) within the PA process, with its potential
to automate 50 -75% of manual tasks.  

Let's look closer at how AI can transform the prior authorization process and
what the transformation could look like for your organization.


THE CURRENT STATE OF PRIOR AUTHORIZATION

Today's prior authorization process is extremely labor-intensive and
time-consuming, as evidenced below in a digram from McKinsey & Company. This
process  involves a lot of moving parts that affect providers, payers, and
patients. While there are accepted guidelines on some issues, the lines are
blurred on others. To get a better understanding and get answers to some of the
most frequent questions, download The Ultimate Guide to Prior Authorization from
our partner, Myndshft. 

The statistics surrounding prior authorization underscore the urgency of the
situation. According to a survey by the American Medical Association (AMA), more
than 84% of physicians describe the burden of PA as high or extremely high, with
each physician completing an average of 31 PAs per week. This not only leads to
administrative overload but also can delay patient care. In some cases, these
delays can have significant health implications, especially in time-sensitive
situations. In some instances, these delays can have dire consequences,
emphasizing the critical need for a streamlined and efficient process.




THE CRITICAL CHALLENGES OF PRIOR AUTHORIZATION

The statistics surrounding prior authorization underscore the urgency of the
situation. Over 84% of physicians report that the administrative burden of PA is
high or extremely high, with each physician dealing with an average of 31 PA
requests per week. This labor-intensive process, reliant on outdated
technologies such as fax machines and phone calls, not only creates a
significant workload for healthcare providers but also leads to delays in
patient care. In some instances, these delays can have dire consequences,
emphasizing the critical need for a streamlined and efficient process.


UNLOCKING EFFICIENCY WITH AI

AI has the potential to significantly alleviate the burdens associated with PA.
By automating routine tasks, enhancing decision-making with predictive
analytics, and improving communication channels, AI can streamline the PA
process in several ways:

 1. Automating Routine Tasks: AI can automate the collection and processing of
    patient data required for PA. By integrating with Electronic Health Records
    (EHRs), AI algorithms can extract necessary information, fill out forms, and
    submit them to insurers automatically. This reduces manual errors and saves
    substantial time for healthcare providers.

 2. Predictive Analytics: AI can analyze historical data to predict the
    likelihood of a PA request being approved. This helps healthcare providers
    make more informed decisions about whether to pursue a PA request or
    consider alternative treatments that do not require PA.

 3. Natural Language Processing (NLP): AI-powered NLP can interpret and respond
    to written and spoken requests from healthcare providers. This technology
    can be used in chatbots or virtual assistants to help providers navigate the
    PA process more efficiently.

 4. Enhanced Communication with Payers: AI can facilitate better communication
    between healthcare providers and insurance companies. Through AI-driven
    platforms, providers can track the status of PA requests in real-time,
    receive notifications about missing information, and get quicker responses
    from payers.


CHALLENGES AND CONSIDERATIONS

While AI offers promising solutions, there are challenges to consider:

 1. Data Privacy and Security: Handling sensitive patient data requires strict
    adherence to privacy laws and regulations, such as HIPAA in the United
    States. Ensuring the security and confidentiality of data within AI systems
    is paramount.

 2. Integration with Existing Systems: Integrating AI solutions with current
    healthcare IT infrastructure, such as EHRs, can be complex and require
    significant resources.

 3. Provider and Patient Acceptance: Encouraging healthcare providers and
    patients to trust and adopt AI-driven processes is crucial. This involves
    education and training on how these systems work and their benefits.

 4. Regulatory Compliance: AI systems used in healthcare must comply with
    various regulatory standards. Ensuring these systems are up to date with
    changing regulations is vital.


LEAD THE WAY IN AI-POWERED PRIOR AUTHORIZATION WITH NEXAUTH

 



 

Traditional prior authorization processes, known for their time-consuming and
complex nature, often delay patient care and impose heavy administrative burdens
on healthcare providers and payers. NexAuth, developed in collaboration with
Google and Myndshft by Productive Edge, offers a compelling solution.

 

> "At Google Cloud, we are committed to harnessing the power of technology to
> transform healthcare. Our collaboration with Productive Edge on NexAuth
> demonstrates how leveraging cutting-edge AI and machine learning on processes
> like prior authorization reduces administrative burden, time to care, and
> cost. NexAuth can streamline existing workflows relatively quickly in a
> secure, scalable environment. The benefits add value to payers, providers,
> and, most importantly, patients waiting for care." - Amy Waldron, Director,
> Healthcare & Life Sciences Strategy & Solutions

 

By harnessing the power of AI-enabled capabilities, NexAuth equips healthcare
payers to modernize PA processes, ensuring patients receive the timely care they
need without the red tape. This AI-driven approach is not merely about boosting
operational efficiency; it represents a critical move towards a more
patient-centered healthcare system, marking a significant stride in the
evolution of healthcare delivery.



A CLOSER LOOK AT NEXAUTH



MODULAR, AI-ENABLED SERVICES

NexAuth's strength lies in its modular design, offering flexibility to
healthcare payers to adopt one or all of its services based on their specific
needs. These services include:

 1. Intake: Leveraging Google Cloud’s Document AI and Vertex AI services,
    NexAuth’s Intake feature streamlines PA submissions through AI-enabled
    document processing and validation, promising to cut manual attachment
    processing costs by 50%.

 2. Case Validation: Utilizes smart software to verify patient details against a
    database of over 2,000 insurers, ensuring accurate and up-to-date insurance
    coverage for each case. This AI-assisted technology harmonizes compliance
    and can potentially decrease regulatory-related denials by up to 25%.

 3. Clinical Recommendation and Clinician Review: These services harness Vertex
    AI to analyze submission data, policy coverage, evidence-based data, medical
    history, and guidelines. They provide personalized approve/deny
    recommendations and assist clinicians in reviewing PA requests more
    efficiently, summarizing information and responding to queries to accelerate
    decision-making.

By integrating these services seamlessly with existing PA workflows, NexAuth
offers immediate value and aligns with long-term strategic objectives. The
benefits are manifold:

 * Automated Decision-Making: Accelerates the PA process, drastically reducing
   operational costs and decision times by up to 30%-50%.
 * Reduced Administrative Burden: By automating routine tasks, NexAuth minimizes
   manual work, enhancing efficiency and enabling healthcare payers to do more
   with less. This automation is capable of reducing manual workload by 30%-50%,
   directly impacting the bottom line.
 * Enhanced Patient Care: The efficiency brought about by NexAuth leads to
   faster patient care and reduced system frustrations, culminating in a more
   efficient, patient-focused healthcare experience.

Healthcare payers leveraging NexAuth can expect to handle increased PA requests
without adding staff, harmonizing compliance across processes, and significantly
decreasing the time and costs associated with PA decisions. With NexAuth, the
path towards a more efficient, patient-centered healthcare system is clearer and
more attainable than ever.


THE FUTURE IS NOW

The push to modernize prior authorization is clear, and tools like NexAuth offer
healthcare payers a way to lead this change, ensuring patients receive care
swiftly, cutting through red tape. This shift towards AI-driven PA processes
marks a crucial move towards patient-focused healthcare, streamlining service
delivery and enhancing outcomes. NexAuth not only simplifies the PA process but
also aligns with the evolving landscape of healthcare, where efficiency,
accuracy, and patient satisfaction are paramount. By embracing AI, such as
NexAuth, the healthcare industry can transform PA into a more effective,
fraud-resistant, and patient-aligned procedure, heralding a new era of
healthcare management that benefits all stakeholders.

To learn more about  integrating AI into your prior authorization processes, get
in touch with one of our experts today.

RAHEEL RETIWALLA

Chief Strategy Officer at Productive Edge

More articles from Raheel Retiwalla


GUIDE


THE ULTIMATE GUIDE TO PRIOR AUTHORIZATION

Get a deep dive into prior authorization with insights into health insurers'
cost-control measures, essential approval details, and innovative automation
strategies.

Download Guide


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