Cleveland-based MetroHealth has improved the speed and success of its medication prior authorization process with the help of AI, cutting submission times from 18 hours to around five minutes and increasing approval rates by 15%.
Ryan Mezinger, senior vice president and chief pharmacy officer at MetroHealth, told Becker’s the health system has adopted AI to transform what was once a manual, time-consuming and sometimes inconsistent process with prior authorizations.
“It [could take] upward of two weeks for a submission to be submitted to the insurance plan, just because they needed to find time and it wasn’t a proactive prior authorization process,” he said.
About three years ago, the health system centralized its prior authorization process under the pharmacy department, aiming to streamline access across all of its providers and pharmacies. Initially, the team handled the submissions manually, combing through medical records to complete complex and varying insurance forms.
This changed a year ago, when the pharmacy team adopted an AI-powered solution that automates much of the work. The new software scrubs patient records and pre-populates the necessary forms for review and submission.
“Now it allows the technicians to do more of the financial assistance piece,” Mr. Mezinger said. “This AI tool has really helped us fill out the form more completely, and that’s where we’ve increased our approval rating by 15% on initial submission.”
Before implementing AI, even the streamlined pharmacy-led process averaged 18 to 24 hours per submission.
“It’s still that same process where it’s going into our pool, notifying the provider that authorization is required, but now when the form populates, it’s on average, about four and a half, five minutes for a technician to submit the form.”
As a result, Mr. Mezinger emphasized that patients are often approved for treatment the same day the prescription is written as opposed to several days to more than a week.
In one standout case, he said, a hepatitis C patient was prescribed medication in the morning, the health system submitted the prior authorization in five minutes, received insurance approval within three hours and had the medication in the patient’s hand within seven hours.
Beyond speed, the AI implementation has freed up pharmacy staff to focus on helping patients find financial assistance, such as copay cards, foundations and grants, and now pharmacists are in the clinic more often to support patients and providers directly.
Mr. Mezinger said this is only the beginning of the AI tool’s role in pharmacy and healthcare operations.
“It’s patient first [and] foremost, the more we get AI and technology on board to take away some of these day to day, non-patient-facing tasks to allow our technicians and pharmacists to really focus on the patient facing outcomes,” he said.
