Many healthcare organizations invest time, money, and resources to improve their prior authorization process. Through technology and expertise, payers and providers can streamline prior authorization automation, reduce costs, increase revenue, and improve the physician and patient experience.
Despite all the automation innovations that exist today—Robotic Process Automation (RPA), Machine Learning (ML), and Artificial Intelligence (AI)—prior authorization automation remains a complex challenge with a myriad of disparate payer and plan-specific procedures and processes.
Many organizations have invested countless hours and financial resources in authorization automation technology, only to realize the juice wasn’t worth the squeeze. Despite the good intentions of numerous technology vendors attempting to automate prior authorization functions, access to standardized electronic authorization transactions is still very limited.
The most prevalent technology in use today for authorization automation employs the use of “bots,” which are basically computer scripts or routines developed using RPA. Think player piano. Bots emulate a user performing manual authorization functions, such as searching a payer portal or website to determine if a procedure requires prior authorization based on the insurance payer and plan-specific rules. Other common processes bots can perform include authorization requests/submissions through a payer’s online portal, inquiries to check the status of previously requested authorizations, and other similar functions.
Challenges with prior authorization automation
Although the industry has recognized some success utilizing these technologies, many gaps still exist that require human intervention. Portals often utilize decision trees to determine if a procedure is medically necessary or if it is the best or next logical procedure in the diagnostic or care continuum. These situations often require human intervention, thus reducing the effectiveness of the technology. Often, clinical documentation or medical records are requested. Though some of these requests can be automated using bots, entire medical records are often submitted, requiring payers to sift through and locate the pertinent information, potentially resulting in approval delays.
Payer connectivity is another challenge that limits authorization automation. Only a handful of payers support the EDI X12N 278 transaction set, even though it was mandated within the ACA and required payer adoption by Jan. 1, 2016. Bots require consistency to perform properly. Changes to websites and portal pages, user login credentials that expire, and MFA (multifactor authentication) often create challenges. Some payers explicitly prohibit the use of bot technology, fearful that bots may overload their systems or cause other unforeseen problems.