The administrative burden of utilization review processes like prior authorizations and concurrent review has long been a thorn in the side of healthcare providers. While prior authorizations have garnered significant attention in recent years, concurrent review is an equally important, yet often overlooked, component of utilization management. Fortunately, the emergence of artificial intelligence (AI) solutions offers promise in streamlining both of these critical processes.
Prior Authorizations: An AI-Powered Solution
Prior authorizations are an unfortunate must-have in healthcare, with an estimated 50 million such requests made in 2023. The time-consuming nature of this task, with physicians spending an average of 13 hours per week on prior authorizations, has led many to seek technological solutions.
Enter AI. Dr. Heather Bassett, Chief Medical Officer of Xsolis, explains that AI holds tremendous potential to automate and expedite prior authorization processes. Generative AI, for example, can effectively summarize clinical information and aid in creating appeal letters, significantly reducing the manual effort required.
Dr. Bassett notes that AI could potentially save physicians 70-80% of the time they currently spend on prior authorizations. However, she cautions that adoption of these new technologies can be challenging, as physicians may be hesitant to change their established workflows. Building trust in the accuracy and reliability of AI-powered solutions will be crucial to driving widespread acceptance.
Concurrent Review: The Overlooked Opportunity
While prior authorizations may have stolen the spotlight due to the looming January 2027 CMS deadline, concurrent review is an equally important, yet often undervalued, component of utilization management. Concurrent review evaluates the medical necessity and appropriateness of ongoing healthcare services, ensuring patients receive the right care in the right setting.
According to Dr. Michelle Wyatt, Senior Director of Utilization Review Services at Xsolis, concurrent review has significant financial implications for healthcare organizations. Medical necessity denials alone cost providers an estimated $2.5 billion annually, often due to misalignment between payers and providers on what constitutes medically necessary treatment.
Moreover, avoidable delays in care during the concurrent review process can lead to prolonged hospital stays, costing an estimated $1.5 billion per year. These delays can also contribute to adverse events and hospital-acquired infections, further burdening the healthcare system.
Integrating AI into Concurrent Review
Just as AI can streamline prior authorizations, it holds immense potential to optimize concurrent review processes. By continuously evaluating the medical necessity of ongoing treatments, AI-powered concurrent review can minimize delays, ensure timely access to care, and facilitate smoother transitions of care.
“Concurrent review presents a strategic opportunity to optimize care delivery and coordination,” explains Dr. Wyatt. “While it might not directly impact the immediate cost to the patient, it streamlines the process for providers, allowing them to focus on delivering quality care.”
Investing in AI-driven concurrent review solutions can yield significant benefits, including reduced avoidable hospital days, improved patient outcomes, and more efficient utilization management. However, like prior authorizations, the adoption of these technologies will require healthcare organizations to address the trust and change management challenges that often accompany new innovations.
A Holistic Approach to Utilization Review
Ultimately, the key to unlocking the full potential of utilization review lies in a holistic, AI-powered approach that addresses both prior authorizations and concurrent review. Focusing solely on prior authorizations, while neglecting concurrent review, leaves a significant opportunity on the table.
By leveraging AI to streamline both processes, healthcare organizations can achieve greater efficiency, reduce administrative burdens, and ultimately deliver better care to patients. As the healthcare landscape continues to evolve, embracing AI-powered utilization review solutions will be crucial for providers seeking to navigate the complex web of reimbursement requirements and ensure the financial viability of their operations.
Learn more about the price tag when concurrent authorization processes are not optimized with the latest technology.
Read the latest success stories from health systems using AI-driven solutions to align more quickly with their health plan partners, reducing administrative waste and avoidable denials to transform payer-provider relationships.
