Overview
Health plans encounter significant operational and financial challenges due to the Prior Authorization (PA) process. The 2021 CAQH Index identifies PA as a particularly costly and labor-intensive transaction, with average costs to payers between $80 to $120 per review, leading to a total expenditure of $305 million in 2019—$202 million of which was due to manual processes. The bulk of PA work, such as necessity checks, submissions, requests for additional documentation, and clinical reviews, is still performed manually through phone, fax, and email. This situation is further complicated by the increasing volume of requests, constantly evolving regulations, and diverse payer policies, all of which contribute to a rise in errors, extended turnaround times, anvvd inflated care costs due to delays or denials.
Our Prior Auth Solution addresses these challenges by leveraging AI for documentation and review, significantly cutting down on manual work, reducing errors, and accelerating decision times, leading to improved health outcomes and higher satisfaction levels.
The Difference AI Can Make
> 50%
Savings in Prior Auth Intake Across Channels
> 98%
Prior Auth Accuracy Rate
80%
Reduction in Prior Auth Processing Time
> 80%
Touchless Prior Auth Resolutions
30%
Reduction in Resubmissions
>80%
Touchless
Prior Auth Resolutions
30%
Reduction
in Resubmissions
Inside Prior Authorization
Simplify Prior Auth Processing with AI
Data Extraction
Our solution handles prior auth intake across channels – fax, email, portal – extracting and processing unstructured requests and documents into actionable data.
Smart Intake
The system does real-time verification of request for completeness and accuracy. It automatically issues requests for additional information (RFIs) to fill documentation gaps, preventing delays and denials.
Determination
Our system customizes to prior auth variations, considering product types, employer groups, and gold carding exclusions, to determine PA necessity according to plan-specified requirements and exceptions.
Authorization
The solution works with rules systems to auto-approve PAs and streamlines manual reviews of pended prior auths and appeals by highlighting key information and pre-populating clinical reviewer checklists.
Drive Prior Auth & UM Efficiency with Flexible AI
Model Tuning
Adaptive Learning
Seamless Integration
Model Tuning
Data-Driven Model Tuning and Rule Updation
Our system can adapt to plan, product type, and employer group variations. It can also accommodate variations due to state-level mandates, gold carding exclusions, and plan-specific Utilization Management (UM) strategies and interpretations of clinical literature.
Adaptive Learning
Adaptive Learning for Enhanced Accuracy
Our solution has the ability to identify regional healthcare patterns, adjust to state-specific mandates, and respond to shifting policies, ensuring decisions that are both precise and adaptable
Seamless Integration
Seamless Integration into Existing Systems
Intelligent Prior Auth Solution can integrate with your payer Auth intake, Care Management, Utilization Management systems, and clinical policy packages, enhancing and complementing existing workflows.
Coordination of benefits (COB)
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Claims AI
Improve auto adjudication rates and claims quality with real-time intelligent claim edits. Predict and orchestrate potential claim suspensions to reduce and resolve any manual intervention.
Intelligent Contract Management
Leverage Generative AI and LLMs to extract, comprehend and integrate contract information for downstream Payer operations. Improve data quality, compliance and contract configuration throughput…
