Background and Objective:

Prior authorization or prior approval is a health plan cost-control process by which physicians and other health care providers are required to obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. It is one of the most common and time-consuming tasks in the healthcare revenue cycle process and most of the health plan denials and underpayments are attributable to prior authorizations. It is therefore important to get timely approvals at the point of the physician's order or referral. It provides a better opportunity to ensure the receiving provider gets appropriately paid and the patient gets prompt service.

A recent survey from the American Medical Association (AMA) found that 88% of physicians reported that prior authorization generated high or extremely high burden, with physicians completing an average of 41 prior authorizations each week, the survey also revealed that prior authorizations frequently delayed access to necessary care for patients or led patients to abandon their treatment altogether due to the waiting period or other prior authorization issues.

About the Solution:

The solution built on Microsoft technologies is a workflow based prior authorization automation process with automated clinical appropriateness checking. Through artificial intelligence-powered clinical reviews, the tool can determine if the health plan will cover the needed services almost immediately.

Key features:

The solution features multifaceted strategies including rewarding providers who have a high percentage of approvals and reducing manual burdens involved in the prior authorization process and introducing proactive authorizations to help decrease time to decision such as:

• Recognize clinicians who are regularly approved for prior authorization by lifting the requirements for a limited time
• Eliminate prior authorization for drugs, medical services and equipment that are regularly approved
• Use AI-ML models to analysis the prior authorization request and provide recommendation for a timely decision
• Patients with pre-diagnosed medical conditions can be preapproved for treatments and therapies that are typically requested for their conditions
• Clinical Decision Support and real-time pharmacy benefit checks can be used to inform clinicians for a timely decision and increase quality of care as well.