Bevey Miner

home

authors

bevey-miner

on the effects of applying artificial intelligence to the prior authorization (PA) process. The research revealed that leveraging AI in strategic ways will benefit the entire healthcare ecosystem for providers, payers, and members.

“Our analysis suggests that artificial-intelligence-enabled prior authorizations can automate 50% to 75% of manual tasks, boosting efficiency, reducing costs, and freeing clinicians at both payers and providers to focus on complex cases and actual care delivery and coordination,” said the McKinsey study.

To understand why McKinsey’s researchers were able to make such a bold claim, let’s step back and review how most health insurers receive prior authorization requests today. A 

found that nearly half (47%) of providers always or nearly always submit PAs for medical services by paper fax machines.

That means a large portion of the PA requests your staff has to process come in as unstructured data on fax machines. Digital fax pages are technically “images,” as well, not data. And that means your staff needs to manually review these faxes, prioritize the cases, and often re-enter the information into a database by hand.

 found that manually reviewing and responding to PA requests — communicating with providers by phone, mail, or paper fax — costs payers an average of $3.14 per transaction. The researchers also estimated payers could reduce this average cost to just pennies per transaction, while also ensuring timely delivery of care, by automating and digitizing at least part of the process.

Why? Because the burdens of reviewing and processing unstructured data — in PAs submitted as faxes, paper or cloud — creates enormous challenges for payer organizations. Just a few examples:

Payers have no way of automatically sorting and prioritizing traditional faxes according to member need or urgency.

Manually reviewing and acting on fax-based PAs takes staff longer and results in slower responses to all PA requests.

Manual data re-entry of unstructured fax content increases the chances of human error — which can both lead to poorer health outcomes and increase the ultimate costs of member care.

Think of it this way: If you received 100 names in an Excel file, and you needed to rearrange them into alphabetical order, that task would require only a few clicks. The software has the ability to recognize the letters in the names and the built-in intelligence to order them from A to Z.

But now imagine that instead, you received those 100 names on a piece of paper. Resorting them alphabetically will no longer be a simple matter of clicking a few buttons. Someone is going to need to manually rewrite every name on the list — or manually type them into a database.

That’s a very simple analogy, but it underscores the difference between an AI-enabled prior authorization process and the name-on-paper process that your staff is probably struggling with every day.

Manually handling PAs as inbound fax documents is among the least cost-effective ways to manage the process. But unfortunately, as long as providers continue to rely on fax machines and paper faxes to transmit health data — and an 

found that 89% still do — you’re going to need to find a more efficient way to review and respond to those requests. Fortunately, you do have options.

Even if your providers continue to submit their PAs using fax machines, your staff doesn’t need to receive the requests as hardcopy documents at your end.

The right digital cloud fax solution — one designed to meet the unique needs and constraints of the healthcare industry — can ingest inbound fax content into EHRs or other records systems. It can also leverage basic optical character recognition (OCR) to identify key data in your faxes, such as member names, ID numbers, names of
physicians and so on.

This simple addition to your organization’s digital environment can remove several time-consuming, manual steps from the review process — to help your staff streamline their PA responses and ultimately save your organization money.

Natural language processing (NLP) takes digital cloud faxing another important step toward automating the handling of prior authorizations — or any inbound fax content that your staff would otherwise need to manually review and process.

NLP embedded in your cloud fax platform will be able to automatically sort and organize key information in an inbound fax, and even take a next step if necessary. For example, you can instruct your NLP solution to scan every inbound fax for key terms — “urgent,” for example — and prioritize those requests by sending alerts to the right people in your organization.

Because NLP employs machine learning, it will continually grow more adept at identifying key terms and concepts as it consumes more data. It can even learn to read handwritten notes on fax pages.

Your organization will see the greatest operational benefits — both in terms of reducing the costs of your prior authorization responses and helping to deliver more timely care to your members — when you employ artificial intelligence to your PA processes.

Artificial intelligence brings together all of the capabilities listed above while adding layers of learning, thinking, and continuous improvement to your fax solution.

The McKinsey study concluded that “an AI-enabled workflow requires fewer steps,” automating most of the administrative steps most payers handle manually today. AI can also benefit payers by sorting requests according to high and low priority as well as those that can be handled by RNs and those that need doctor input.

Because fax (both paper and digital) remains one of the most common methods for providers to submit prior authorization requests, payers need to employ new tools and technologies to make their ability to receive, review, and process these requests as efficiently and reliably as possible.

The best, easiest way to do this today is to implement the right digital cloud fax solution with built-in AI and NLP capabilities. Doing so will lessen the burden on payers’ staff, streamline their ability to respond to PAs, reduce the overall costs to the company, and improve member outcomes.

Bevey Miner is health IT strategist for Consensus Cloud Solution.

Articles

Many prior authorizations requests still come in by fax. Natural language processing and artificial intelligence can extract and use information from faxes. 


How AI Can Help Payers Streamline Prior Authorizations to Save Time, Improve Member Care

Imagine being the quarterback who is unable to call the play until after the ball is snapped. Think of the chaos as tackles, running backs and other players do their best to advance the ball.  But, with no direction, they are destined to fail.

Health plans and other payers are like that quarterback in terms of timely access to patient data. As patients move from physician to physician and care setting to care setting, a patient’s health plan is the only entity that can see a complete patient picture. The difficulty is that information generally isn’t compiled until a claim is submitted.

Admission, discharge and transfer (ADT) notifications have become more common as federal mandates require notification of a patient’s primary care physician or next healthcare destination as patients are admitted to and discharged from the hospital. But real-time event notifications to health plans, the true quarterbacks of the care process, can benefit patients with multiple health issues and comorbidities. By directing patients to the proper follow-up care, managing preventive screenings, and playing a more active role in patient care, primary care providers utilizing health plan recommendations can reduce costs while increasing the effective management of patient conditions, resulting in overall better health.

Demographic research from the CDC  shows that more than half of American adults (51.8%) have at least one of 10 

, and 27.2% have two or more. The Advisory Board estimates that 

 with one or more chronic conditions whose symptoms are readily ignored — such as uncontrolled high blood pressure — will become a high-risk patient and incur treatment costs far in excess of average. Care management (facilitated by the patient and his/her care provider) can reduce rising-risk patient escalation by one-third, states the Advisory Board, noting that intervention at the provider level is key.

Managing chronic conditions and getting people to receive recommended screenings such as mammograms and colonoscopies was a challenge even before the pandemic hit. During the initial nationwide shutdowns in March 2020, the incidence of preventive screenings dropped by more than 80%, depending on the study and the time frame, and fewer screenings inevitably leads to higher cases of disease.

Estimates from the National Cancer Institute 

 over the next decade from just breast and colorectal cancers. Imagine the cardiology, urology, gastrointestinal, and general practice visits that were missed and the number of emerging conditions that were left undiagnosed. Helping people manage their chronic conditions improves patient health, while reducing the overall cost of care, paradigms that barely existed during the pandemic shutdowns.

More than 90% of health plans in the U.S. — HMOs, POS plans and PPOs —use the Healthcare Effectiveness Data and Information Set (HEDIS) to 

 and care quality. Managed by the National Committee for Quality Assurance (NCQA), HEDIS comprises one portion of NCQA's accreditation process.

For consumers, HEDIS measures are used to compare health plans against others and against regional and national benchmarks that include 70 unique measures of process, structure, outcomes and patient satisfaction. HEDIS measures address the continuum of care from prevention and managing chronic conditions to acute care.

Besides the obvious profitability motive, health plans are invested in the health of their patient populations. Unchecked diabetes, for example, can lead to expensive hospitalizations and other interventions that impact patient quality of life. But caregivers can’t manage care according to a health plan if they don’t know what a patient’s status in a timely manner.

Health plans assist caregivers in learning — eventually — what’s going on with patients, but that’s not sufficient to support the Triple Aim of better individual and population health while reining in costs. Hospitals already must send ADT notifications to downstream providers, and sending real-time information to payers can be accomplished without increasing expense or workload.

Notifications can address critical events including admission, discharge, gaps in care, and abnormal tests that are communicated in real time. Creating visibility into member utilization can help health insurance providers identify gaps in care and improve health outcomes. Current technology allows notifications to seamlessly flow to payer case management systems, so quality of care can be maintained.

Real-time event notifications to an enterprise care management solution can improve payer/provider relationships and speed patient care delivery. Closing critical communication gaps streamlines transitions of care and improves care coordination as a patient navigates the healthcare landscape. Notifications can engage providers within existing workflows, rather than add to administrative burden.

Automated care alerts to providers within their EMR workflow can trigger appropriate follow-up care after a member utilizes an emergency room or inpatient facility. By developing a follow-up process for patients using care plans, 70% of provider sclosed care gaps.

 The benefits are tangible for patients through early diagnoses, leading to timely medication reconciliation and lower readmission rate.

True interoperability has long been the holy grail of healthcare communications. But with so many competing medical information systems that focus on physicians, hospitals, labs, imaging, payers, and more, communication among IT systems remains elusive. To deliver better and more timely care management to patients, payers should work with providers to adopt a technology-agnostic communication strategy to receive real-time event notifications and take their rightful place as quarterbacks of patient health.

 serves as global health IT strategy/chief marketing officer for 

 Consensus: 2021 Industry Trends Survey for Healthcare (2021)

Real-time notifications accelerate accurate care management. To deliver better and more timely care management to patients, payers should work with providers to adopt a technology-agnostic communication strategy .

Bevey Miner

Articles

How AI Can Help Payers Streamline Prior Authorizations to Save Time, Improve Member Care

Payers Should Be the Quarterbacks of Patient Care