Streamlining Prior Authorizations Using AI-Augmented Capture & RPA

In the wake of the COVID-19 crisis, companies are looking for tools that hold the promise of cutting costs and boosting revenue. This trend is especially apparent in the healthcare sector, where revenue is directly related to process efficiency in areas ranging from prior authorizations, to enrollment, to referrals, to pharmacy management. In this article we will examine some of the technologies, like Artificial Intelligence (AI), Robotic Process Automation (RPA), and Intelligent Capture, that Alitek is leveraging to make healthcare companies more agile and profitable in 2020 and beyond.

Benefits to Healthcare Providers, Patients, and Physicians

Using the technologies described in this article, Alitek has helped healthcare companies achieve tremendous financial results. For one client, we were able to reduce costs by up to 80% in their manual triage process flow. For another, we helped increase SLA compliance leading to an improved CMS Star Rating and increased reimbursement from Medicare. In perhaps the most striking example, we saw how automation can allow for an average turnaround of prior authorizations in 2.5 days, much less than average for the industry [1].

Not only has Alitek helped healthcare providers leverage RPA and AI-augmented Capture to streamline existing content channels and reduce operational cost, we have also seen how automation can benefit both patients and physicians. For physicians, improvements in the prior authorization process decrease administrative burdens and cost in their practices. For patients, they enhance patient care delivery and reduce wait times for needed treatments. Given the increasing demands of patients, physicians, and regulators for efficient processing, it will be imperative that healthcare providers sustain and accelerate industry trends in process automation.

Healthcare Challenge – Prior Authorizations

Prior authorizations present a unique challenge to the healthcare industry. The prior authorization process gives health insurance companies a chance to review how necessary certain medications or procedures may be in treating a patient’s medical condition. It is an important process, but it is widely recognized as labor-intensive, costly, and time-consuming for healthcare insurance payers to triage the enormous number of incoming requests. Review processes typically require significant human assets to examine incoming materials and often involve multiple iterations with physicians.

Unfortunately, delays and errors in the prior authorization process have a real impact on both patients and health care providers, reducing the timeliness and quality of patient care and causing providers to miss their service-level agreements. In addition, inaccurate evaluations often lead to costly appeals and grievances.

While these challenges have always existed, they have been exacerbated by COVID-19 as data-entry workers have been called to work from home. In addition, there is evidence that the regulatory environment is about to become even more challenging for Medicare providers. The Medical Group Management Association (MGMA) has expressed support for using the Medicare Star Ratings Program to address prior authorization challenges for Medicare providers [2]. Specifically, they have supported updating the operating rules that apply time frame constraints on prior authorization processes, giving health plans two business days to review and respond to a prior authorization request. Since the Star Ratings are directly tied to Medicare reimbursement, process inefficiencies could become a financial liability for healthcare providers. Suffice it to say, the prior authorizations process is ripe for improvement.

Automation Solutions

To meet this need, Alitek has helped healthcare providers make demonstrable improvements to the patient care delivery process by leveraging three powerful but complementary technologies:

• Intelligent Capture software, such as OpenText Intelligent Capture, allows companies to automate the intake, classification, and routing of forms and other documentation. It standardizes the processing of high-volume communication channels, including fax, paper, email and electronic forms. When applied to the challenge of prior authorizations and other healthcare processing needs, Intelligent Capture offers a sea change over traditional processing methods.
• Artificial Intelligence (AI) software, like OpenText Magellan, integrates with capture processes to deliver the cutting-edge ability to triage unstructured content. Prior authorizations often include supporting documentation such as physician referrals, and with Magellan, it becomes possible to extract information like symptoms, conditions, or medications from referrals, even if they do not explicitly mention the terms.
• Robotic Process Automation (RPA) allows companies to emulate and automate the actions of humans to execute business processes. By using Alitek’s Robotic Process Model, our customers deploy Bots to assist with the capture of high-volume incoming communications while interacting with AI processing tools to streamline the prior authorization process.

References

1. Transforming the Prior Authorization Process to Improve Patient Care and the Financial Bottom Line, https://www.mgma.com/insights/revenue-cycle/transforming-the-prior-authorization-process-to-im
2. 2021 Medicare Advantage Star Rating Program, https://www.mgma.com/getattachment/31c327cd-7107-4a8b-8ffc-fd385059ff4f/MGMA-MA-Plan-Star-Ratings-Comments-Final.pdf.aspx?lang=en-US&ext=.pdf

About Alitek

Alitek is a leader in information based digital transformations. We help organizations improve business outcomes, increase efficiency, and reduce risk, through better management of information. Our experienced team works with you to build a unique strategic plan based on your specific needs, no matter the size of your company.