Prior Authorization Process Automation

Prior Authorization Automation

How to solve prior authorization challenges which cause delays in patients getting the care they need. 1 in 3 US providers say Prior Authorization processing delays have led to an adverse event for patients. How do we ease the administrative burden on providers and ensure that patiens have access to care quickly when they are in need? Prior authorization was designed to protect resources and save money, but the submission & obtaining approval process ha become a bottleneck:

How to Solve Prior Authorization Challenges
Which Cause Delays in Patients Getting the Care They Need

1 in 3 US providers say prior authorization processing delays have led to an adverse event for patients. How do we ease the administrative burden on providers and ensure that patients have access to care quickly when they are in need?

What is Prior Authorization?

“A request from a provider to a health plan (Insurance Payer) to obtain authorization for healthcare services or a response from a health plan for an authorization.” — CAQH
- Prior Authorization Asks: How do insurance companies determine whether or not to cover a procedure, service, or medication?

Prior authorization was designed to protect resources and save money, but the submission & obtaining approval process has become a bottleneck

Process of Submitting Prior Authorization

Manual Method

Manually check patient insurance details to determine if prior authorization (PA) is required for the planned procedure or service
- May involve calling the patient’s insurance company, waiting in call queue, or checking online portals.
Manually read medical charts/clinical documents for required information to determine if the patient meets prior authorization guidelines
Manually submit PA request through Fax or Portal provided by payers
- 15-20 minutes per patient
Follow up with the provider to check the status of the prior authorization being submitted
- Phone calls, emails, and/or frequent logins to the payer’s portals.
If authorization is denied or additional information requested by payer, staff must prepare documentation or submit an appeal letter resubmit
- Steps 2, 3, and 4 repeat
If authorization is accepted, staff must manually update EMR/EHR, add necessary approval documents, and clarify case status before rendering patient care

Automated Method

Orbit AI (combined with HL7, FHIR, EDIX12 and RPA interfaces) retrieves required patient data and medical information
AI voice agent places call to payers to check if Prior Authorization is required for a specific CPT code
Provider completes the necessary Medical Necessity (MN) / clinical notes documents
- Orbit AI reads these documents and validates required information to determine if the patient meets the Prior Authorization guidelines set by payers
Orbit AI prepares PA request and submits it through EDI 278 or Payer Portals RPA
- Uses EDI 278 or RPA to monitor submission status until a decision is made
If a payer denies the request or requests additional information, Orbit automatically identifies the status and retrieves information required
- Only requests that Orbit automation cannot handle get routed to a manual queue
Once the final authorization decision is received, Orbit automatically updates medical records with the auth status by placing approved documents in the EMR
- This ensures the provider is promptly informed of PA status, allowing them to proceed with the patient’s treatment

The rigidity and complexity of prior authorization have led to serious side effects

The Unintentional Side Effects of Prior Authorization

On physicians
- Paying extra for medical staff
  - 35% of providers have hired staff members to work exclusively on prior authorization
- Higher costs
  - Per manual authorization:
    - $11 USD spent
    - 20 minutes wasted
  - Increased administrative burden
    - 93% of physicians say prior authorizations leave them with a “high” or “extremely high” administrative burden
  - On patients
    - According to 1,000+ surveyed providers, prior authorization can lead to:
      - Delays in access to care (100%)
      - Hospitalization (25%)
      - Life-threatening events (19%)
      - Disability or permanent bodily damage (including death) (9%)
    - Both patients and providers are worried about these disturbing new trends
      - 27% of physicians say prior authorizations are often or always denied
      - Nearly three in four doctors say that denials have increased somewhat or significantly over the past five years
      - 35% of physicians report that prior authorization criteria are rarely or never evidence-based.
    - And they’re doing their best to make sense of the system
      - 1 in 5 physicians always appeal negative prior authorization decisions
      - But nearly half don’t have the time, staff, or resources to pursue appeals
      - And another 48% say their patients’ health can’t wait for approvals

As many as 70% of current prior authorization processes still rely on manual labor. What if there was an easier way to automate systems and collapse the timeline for patient care?

How Orbit Healthcare AI Powered Solutions are Solving the Prior Authorization Challenges

Electronic prior authorization strategies represent $449M+ in cost savings for the US medical industry
- Orbit’s AI-powered prior authorization automation workflow saves providers an average 60% off all their existing costs
- Replacing the Manual Pre-Auth Process with AI Solutions can
  - Fully automate prior authorization by up to 82% or more and
  - Manage 1.3 million rules used by 300+ health plans
- Orbit can offer a number of benefits in addition to the cost savings:
  - Improved patient experiences
    - Better patient outcomes by reducing the time it takes to render care to patient
  - Streamlined workflows
    - Orbit saves up to 24 hours or more of wasted time per day per provider group that operates with 5 or more prior authorization processing team members
  - More efficiency
    - It takes less than 5 minutes for Orbit AI solution to perform prior authorization processes
  - Better accuracy
    - Orbit prior authorization automation solution captures demographics, insurance and Medical necessity information from documents without human loop eliminating potential manual errors
  - Reduced costs
    - Automated PA systems could save up to $9.60 per authorization for both providers and payers
  - Reduced turnaround time
    - Automated prior authorizations could save an estimated 11 minutes per authorization – a reduction of 55%
  - Reduced dependency on labor
    - Without Orbit, each staff member spends up to 12 hours a week completing prior authorizations