The concurrent authorization process is plagued with challenges for both payers and providers. Inefficiencies like administrative burden, communication gaps, and inconsistent medical necessity determinations lead to increased costs and a poor member experience. In fact, commercial denials have risen 20.2% in recent years, around half of which are ultimately overturned — due in part to the availability and quality of clinical information at the time of initial review, which compounds the aforementioned culprits.
In response, the healthcare industry is undergoing a transformation, as artificial intelligence (AI) reshapes workflows and enables more collaborative approaches between payers and providers.
A new white paper from AHIP SmartBrief, “AI-Driven Collaborative Authorization,” explores how organizations are leveraging this technology to improve the concurrent authorization process.
The Perils of Siloed, Competitive AI
Many healthcare organizations have tried to build their own internal AI solutions for concurrent authorization. However, these often lack the comprehensive data and cross-continuum perspective needed to truly optimize the process. Even large hospitals or plans will have less data, and certainly less heterogenous data, than a technology vendor working with different size organizations throughout the country.
“Provider-focused solutions lack complete data visibility, while payer-focused solutions are disconnected from the real-time clinical environment,” explains Chris Bayham, Chief Operating Officer at Xsolis. “Both of these perpetuate silos and miss opportunities for mutual optimization.”
The AHIP white paper highlights the benefits of collaborative AI platforms that offer shared intelligence, objectivity, and consistency — benefiting both payers and providers. This allows the relationship to shift from transactional to strategic, with a shared focus on data-driven insights to improve decision making and member outcomes.
Xsolis’ Dragonfly Platform: A Case Study
One example of a collaborative AI solution is Xsolis’ Dragonfly platform, which uses real-time predictive analytics to continuously assign an objective medical necessity score and assess the anticipated level of care for every patient. In the case of Dragonfly, its proprietary Care Level Score™ provides a common language for payers and providers, reducing subjectivity, enabling clinicians to work at the top of their license, and focusing discussions on the most critical, time-sensitive cases.
This empowers not only efficient decision-making but creates alignment between payers and providers where it may have seemed impossible before.
When deploying automation on qualifying cases, a time study since validated by multiple health plans, found status determinations take an average of just 9 minutes with Dragonfly Align, compared to 55 minutes using fax — 83% faster determinations.
Users have saved more than $1.5 billion from the use of Xsolis solutions, with the administrative burden reduced by around 2 hours a day, per user.
“The most significant savings are typically driven by reduced administrative burden, faster decision making, and improved accuracy in determining medical necessity,” says Michele Schoen, VP of Health Plan Client Relationships at Xsolis.
Xsolis’ value also lies in its support team, including structured training, a dedicated value realization partner, a clinical or nurse optimization role, and a customer relationship executive assigned to each client.
According to Schoen, those organizations that take advantage of the training and support — committing to process alignment, end-user engagement and leadership buy-in — see the time and financial savings results much more quickly.
The Path Forward
As the healthcare landscape continues to evolve, collaborative, responsible AI will be a key enabler of growth and a differentiator for both health systems and health plans. By embracing this technology, health plans can improve provider relationships, operational efficiency, and ultimately, member outcomes.
Download the full AHIP SmartBrief white paper to learn how your organization can leverage AI-driven collaborative authorization to stay ahead of the curve. Learn more about Xsolis’ Dragonfly solution for health plans.
