Transformative AI to Revamp Prior Authorizations
Tech enablement drives lower costs, lessened provider abrasion
Experts such as healthcare business process management partners have the combined digital solution and skillset: experienced clinicians supported by AI workflows to effectively manage the process and cost. Backed by process re-engineering, automation and digitization of the prior authorization process will ease provider burnout and change the perception of this process. Traditionally, the prior authorization step has been viewed as cumbersome, with high administrative costs running into billions of dollars across the US healthcare sector. BPM partners with experience across both payers and providers can collaborate and bridge gaps to improve the overall ecosystem of population health and give a better dollar accountability and visibility. As a result, transformed, high-value utilization reviews will drive to lower-cost per review using state specific/CMS guidelines and a 99%+ calibration with medical directors on review decisions.
Transforming the front office with the voice assist and context bots results in auto-approvals for high volume procedures. This directly reduces call volume reduction by 10-15%. The next-best action and access to unified knowledge bases have driven a shortening of complex prior authorization calls, for 15-20% savings via handle time reduction. The continuous digital bot and agent monitoring metrics have also resulted in an internal training glide path reduction by 50%, ensuring the quality of outcome at above 99%+. Overall savings in the front office can be at least 20% as skilled resources need no longer work on administrative tasks anymore.
As next steps, any outcomes of clinical decision support that sources from a unified data lake of claims, medical records, and member profiles can be successfully linked with population health outcomes and patient profile stratification. This will result in insights on high risk population analysis, population trends and wellness management, and, finally, risk scoring of individuals and proactive population management. Weaving in provider profiles can also help provide in extension insights on the segmentation, scorecards, and comparative analytics to evaluate provider utilization and abuse, if any.
By Abhishek Danturti Sharma,
Principal, Business Transformation,
Abhishek leads Sagility’s cognitive and AI initiatives in a consulting and solution delivery capacity. Abhishek is responsible for and executes the digital product and innovation agenda across the healthcare organization. Abhishek is an alumnus of the University of Maryland, College Park and BITS-Pilani, India.