The American Medical Association defines prior authorization as any process by which physicians and other health care providers must qualify for payment coverage by obtaining advance approval from a health plan before a specific service is delivered to the patient.. The process is an important aspect of utilization management but often increases the turn around time for critical business transactions.
According to a 2018 AMA survey, preauthorization is responsible for 92% care delays, treatment abandonment and 853 hours per year of wasted staff time which includes 1 hour of physician time, 13.1 hours of nurse time, and 6.3 hours of clerical time per week – or 853 hours per year of staff time, costing $82,975 in labor annually per full time physician.
The healthcare provider was struggling with time consuming, expensive and frustrating PA. It was one of the biggest cause of job dissatisfaction among physicians. Patients were also suffering due to delays in treatment and medication, resulting in dissatisfied experience with the doctors. Resources spent on bureaucracy are resources that are ultimately unavailable to patients.
Accurate and timely determination of the patient’s eligibility provides healthcare providers a clear view on patient’s coverage, out-of-network benefits. Verifying authorization requirement before the service avoids denials and contributes to increase in collections. PA can now be automated submitting requests electronically using a unified interface. Only complex requests and exceptions can be handled by the medical staff, freeing them for higher value tasks.
AiRo Digital Labs deployed an end to end authorization platform using ML algorithm to determine whether the patient requires prior authorization or not. The solution could recognize a CPT code or hcpcs code, match it up with payor rules to determine necessity, and then submit required data for prior approval. It can process both Rx authorizations (EDI 272), and medical service authorizations (EDI 278).
The solution initiated process in less than 30 mins, if a requirement was determined. It auto filled the patient and physician’s information and prompted the medical staff if any additional information was required.
Integrating directly with the HIS, it allowed users to exchange data with payers using either APIs or EDI 278 transactions. Realtime dashboard was available displaying the status of all current, past and denied authorizations. Alerts were sent, when authorization needed attention from the administrator. This helped in scheduling procedures on time.
Capable of completing more than 300 prior authorizations daily, the automated PA solution dramatically improved the success rate. The backlogs were taken care of immediately and the provider could see a substantial improvement in number of pre authorizations completed on time. The solution is 100% compliant to all payor guidelines and protocols leading to >99% error free audits on all documentation.
In addition to improving the patient experience by having authorizations go through quickly and freeing up staff for more important (and less frustrating) tasks, AiRo Digital Labs can help reduce the number of rejected and denied claims, which can increase reimbursements and reduce days in A/R.
With more than 20+ modules for automating revenue cycle management, AiRo is enabling its clients to achieve strategic and financial objectives in today’s competitive environment. With AiRo’s automation solution which can preemptively identify problems, alert the necessary staff and allow for corrections BEFORE submitting a claim, the organization can now usher in a new, more effective approach to revenue cycle management.
A large healthcare provider specializing in Cancer, Cardiac, Neurosurgery, Surgery, Electrophysiology, Orthopedics, Primary care and urgent care.
AiRo Digital Labs is an award-winning Chicago-headquartered, Digital 2.0 Consulting firm, with expertise in business transformation through digital convergence of Cognitive Automation, Machine Learning, Voice technology and Industrial IoT. We are strategic advisors for digital future in industries such as Healthcare, Pharma and Life Sciences, Manufacturing, Hi-tech and Retail / CPG. With an agile and collaborative approach, we apply digital convergence to enable sustained business advantage across the 4 dimensions of –cost, speed, accuracy and customer experience.
The AiRo Innovation Factory has developed award-winning solutions to solve everyday business challenges.. Learn how AiRo helps clients on their digital transformation journey at www.airodigitallabs.com
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