Automating Prior Authorization to Enhance Care

The healthcare industry today is more advanced, more robust, and more funded than ever. There is hardly a week that goes by without a new innovation or treatment being developed. However, while progress continues, access to this progress continues to be limited. Not only do millions of Americans lack insurance, but insurance won’t always cover all care.

This is where prior authorization comes into the equation. Prior authorization is the process of a healthcare provider requesting approval for insurance to cover more niche care. Rudimentary and typical processes will have regulations under each insurance company, but there are always exceptions.

Fundamentally, prior authorization process automation is an important tool to ensure that the right coverage is being applied to the right care. Yet in practice, the process of prior authorization is inefficient, wasting time, money, and mental bandwidth. The healthcare industry is notably understaffed, with most workers taking on more shifts than they’d like. There are few processes that these workers want to take on less than administrative ones such as prior authorization.

All of this leads to the development and importance of automating the prior authorization process. Today, one in three providers say that delays in prior authorization have led to adverse events for patients. It’s not just a matter of convenience, automating and streamlining the process could save lives. 

Currently, the manual prior authorization (PA) process is simple, yet tedious and ineffective. The healthcare provider has to see if it’s required, read the patient's chart, submit a request, and follow-up regularly. Assuming the PA is accepted, they update the patient's info and move onto care, if not, the process repeats. 

While technically simple, navigating files, calling insurance and waiting on call queues, and submitting a request all take time. It takes so much time, in fact, that 35% of providers have hired staff to work on PA exclusively. It’s abundantly obvious this is not work healthcare providers want to be doing, but instead have to. 

Automation solves all these issues at once. Typically AI-powered, these automated services will check files, call insurance companies, compile info, and submit requests all at once. They can conduct the process from start to end with no human insight, and in fact reduce human error along the way. 

Of course these processes aren’t perfect, but that’s why there’s a queue for human review when complications arise. A big problem with PA today is that so many requests are simply denied. While some providers have the resources to appeal these denials and submit additional information, most do not. Automating the process makes it possible for smaller scale providers to properly appeal for the authorization they want.

Automation is something which can represent a risk to human jobs, a risk to human development. Yet in this case it represents a way for people to afford unique care, to get care in a timely manner. Most PA processes today rely on manpower, rely on the time busy providers take to submit requests. Moving away from this will save time, money, and most importantly, lives.

Source: Orbit Healthcare