Few topics have more power to stoke controversy in health care circles than prior authorization and artificial intelligence (AI). Put the two together, and you get an instant recipe for sensationalism – cue the images of robots denying claims. However, if health care payers are going to make good on their recent commitment to accelerate decision timelines, increase transparency and expand access to affordable, quality care, they are going to need to infuse their utilization management operations with powerful AI tools. The key will be doing it in a choreographed, strategic way that is fully transparent, explainable and carefully monitored.

Fixing a fragmented system

As part of an industry-wide pledge to fix problems that have plagued the prior authorization process for decades, the nation’s leading health plans have signed on to a series of commitments focused on modernizing and standardizing the process. These include the development of standardized data and submission requirements to support electronic processing, reducing the scope of services subject to prior authorization, ensuring continuity of care when patients change health plans, enhancing transparency, enabling real-time responses and promising to have medical professionals review all non-approved results. The U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) have applauded the plan, and providers have voiced cautiously optimistic support.

Now, the hard part: Delivering on the promise.

That’s no small task. Today, approximately 30% of all procedures require prior authorization, and 91% of providers report that care is delayed due to prior authorization. The sheer volume of provider requests, set against a backdrop of clunky and inconsistent technology and analytics infrastructures inside most health plans and the need for constant cross-referencing with constantly changing evidentiary standards and guidelines, creates a mammoth data processing challenge. Health plans that try to maintain the status quo, while adapting their operations to include more automated approvals and speedier review processes will be hard pressed to achieve the industry’s goals.

Infusing AI into utilization management workflows

Simply adding layers of technology on top of this highly fragmented process will not be enough. Health plans need to reimagine the entire workflow with powerful new technologies that connect once disparate components of the operation from front office intake to middle office clinical review processes to back office clinical audits. In fact, getting this formula right is less about the standalone technology being used and more about the strategy and execution of a solid plan.

For example, from the moment the first provider request enters a health plan intake process, health plans must follow a litany of repetitive, data-driven tasks like benefits and eligibility verifications, HIPAA validations, prior authorization review, clinical determination and cross-referencing with current standards of care and care guidelines and several other steps. All of these steps can be improved dramatically with existing technologies such as digital portals, automated data extraction and voice-based AI to streamline prior authorization requests, reducing administrative burden and processing time. But the real value comes not from tweaking any one of these processes, but from streamlining all of them, so they flow more efficiently in a single, connected system.

That’s why it is so important right now for payers developing their go-to-market plans for prior authorization modernization to address the challenge in a strategic manner that incorporates the following key steps:

  1. Assess your baseline: The first and most critical step to improving the prior authorization workflow is developing a clear roadmap of existing processes and an honest appraisal of where the biggest weaknesses exist. This includes analyzing current denial rates and appeal processes to start identifying inefficiencies.
  2. Identify foundational data: Clean, consistent data-driven insights will be the foundation of any technology initiative – especially those incorporating the use of AI. Health plans need to audit their data to identify potential interoperability issues, knock down data silos between departments and ensure they have a clear picture of their patient population.
  3. Develop a utilization management modernization strategy: Fixing prior authorization requires a well-defined strategy that aligns with both regulatory requirements and business objectives. From establishing a framework for real-time data exchange to determining when and how automation is introduced into the workflow, the entire process needs to be rooted in a clear strategy as opposed to being built in an ad hoc or iterative manner.
  4. Monitor, refine and repeat: Most important of all, health care payers will need to consistently monitor, reassess and refine this process over time, measuring results – both in terms of revenue and patient outcomes – as new technologies and systems are introduced.

Transparency and explainability will be the most important two ingredients in the utilization management workflow when it comes time for the industry to prove it is making good on its promise to fix prior authorization. Steps taken now to establish a clear framework for transformation – and develop the checks and balances for monitoring it – will be the keys to success.

Elizabeth Crawley, RN, BSN, CCM-R, is the Vice President of Clinical and Care Management Solutions at EXL – a global data and AI company – with over 30 years of health care industry experience in leadership roles across the payer, consulting, and delegated services markets.

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