For decades, the prior authorization process has been an albatross for payers, providers and patients. Although utilization management processes are necessary to ensure value-based care, these processes are often labor intensive, inefficient and time consuming. Artificial intelligence (AI) technology has the potential to bring prior authorization decisions to the point of care.
At Becker's Healthcare's Virtual Forum on Payer Issues, YiDing Yu, MD, chief medical officer at Olive, facilitated a conversation with Richard Embrey, MD, medical director at Blue Cross Blue Shield Alabama, about the burden of prior authorizations and how AI can streamline and improve the approval process, during a session sponsored by Olive.
Five key takeaways:
- Payers and providers are on the same side, striving to provide high-quality, cost-effective care. According to Dr. Yu, the Quadruple Aim is the North Star for payers and providers. It focuses on enhancing the patient experience, improving population health, reducing costs and improving the work life of professionals. "We're all trying to solve the same problems," Dr. Embrey said. "Sometimes, we have different priorities and perspectives, but we all want to figure out how to get the best care for our members."
- Payers are seeking more ways to serve and help providers compete. Boutique plans are on the rise, and payers must be able to dynamically compete. "We want to be an A+ plan, not just for our members, but also for the providers," Dr. Embrey said. "We want to pay claims quickly, and we want providers to be able to contact someone when concerns come up." Dr. Yu added that providers not only look at reimbursement rates but also want assistance reducing administrative overhead. "Providers are asking, 'Can you just allow me to do good business? Can I be more efficient? Or are you going to be a hindrance to that?'"
- Prior authorizations are a costly burden to all parties. Seen as a necessary evil, prior authorizations help ensure high-value care. But lengthy checklists, numerous faxes and long lead times burden payers, providers and patients. "More than half of all physician practices have a dedicated employee whose only job is to do prior authorizations," Dr. Yu said. Prior authorization approvals are a massive undertaking for payers and a point of friction with providers.
- Recent solutions have failed. Although decision tree-based solutions are available, they fail to resolve issues or scale properly. "I think we're trying to offer simple solutions to a complex problem," Dr. Embrey said. "We're unable to digest the complexity of care into a checklist. I'm hopeful that AI can address those complexities."
- AI has the potential to make better, more consistent decisions. "AI isn't a duplication of human thought processes," Dr. Embrey said. "Instead, AI arrives at a decision more quickly and accurately. It's not that AI is flawless, but humans are flawed." Organizations should expect greater consistency, higher performance, and fewer adverse events.
"However, it's not just about making a prior auth easier or faster," Dr. Yu said. "It is telling people whether they are getting the right care. That's really the Holy Grail." For example, if a physician orders an MRI for back pain, the AI-based prior authorization system might come back and suggest physical therapy first. "It would be great to have a prior authorization add to the practice of medicine instead of detract from it," Dr. Embrey said.