Prior authorization is a process where healthcare providers must get approval from insurance before giving some treatments or medications. This process is complicated and takes a lot of time. Providers often have to contact insurance companies by phone or online portals to check the status, respond to denials, and file appeals. Different insurance plans like Medicaid, Medicare, and private insurers have their own rules for submitting and appealing requests.
More than 7% of prior authorization requests are denied at first. When this happens, providers need to do more follow-up work. The American Medical Association says that about one in four doctors have seen serious problems for patients because prior authorizations were delayed. These delays can also cause a loss of money for medical practices and increase work for staff. Medical administrators and IT managers try to make these processes faster and more accurate, but talking on hold for a long time or incomplete online data make the process slow.
Automated voice AI agents are software programs that make phone calls and handle tasks usually done by people. They call insurance companies to check the status of requests, find out why some requests were denied, and manage appeals. These AI agents work all day and night without getting tired. They call back at set times and can follow different rules for many insurance companies.
Using these AI agents means less time making repeat phone calls. This frees up staff to do other important jobs like helping patients. For example, the Infinitus AI voice agents make calls to insurance companies to check the status of requests and explain denial reasons. According to Aparna Sridhar Murthy from Infinitus, these agents can get information back to patient support teams quickly, helping them make fast decisions.
Speed of Submission and Follow-ups: AI voice agents like PAULA by Thoughtful AI work up to 10 times faster than humans for submitting and following up on prior authorization requests. They track requests in real time and make calls faster, cutting down approval times by almost half.
Reduction in Denial Rates: These systems connect to electronic health records and check insurance coverage. This helps avoid mistakes and incomplete requests. PAULA has a 98% success rate on the first try, lowering the number of denials.
Appeal Management: AI agents spot when requests are denied and watch over the appeal process at every step. They write appeal letters using medical evidence and track progress until the issue is solved, reducing work for staff.
Improvement in Workflow Consistency: AI agents call back regularly at set times to make sure no appeals or other tasks are missed. This keeps the workflow steady and speeds up decisions.
These improvements bring real results. For example, using Infinitus AI agents sped up decisions by 45% and cut manual follow-up work by 85%. Signature Dental Partners saw a 45% drop in how long it took to get paid after using the PAULA system.
Lower Administrative Costs: Doing prior authorizations by hand costs a lot in labor. U.S. call centers spend almost $14 million a year on insurance calls for these tasks. AI agents like VoiceCare AI’s “Joy” from Mayo Clinic cost much less per successful authorization, saving money.
Increased Revenue Capture: Faster approvals mean less delay in treatment and fewer lost payments. Denied or incomplete authorizations cause claim delays and money loss. Automation by companies like AGS Health lowers denials and improves payment rates by up to 6%, helping providers get paid faster.
Staff Efficiency and Reduced Burnout: Repeated phone calls cause workers to get tired and stressed. AI handles these routine tasks, freeing staff to focus on patient care. Sarfraz Nawaz, CEO of Ampcome, noted that AI helps healers by taking away boring clerical work at a time when there is a shortage of healthcare workers.
Improvement in Patient Satisfaction: AI reduces the time patients wait during prior authorization. Metro Health System cut patient wait times from 52 minutes to less than 8 minutes by using AI, helping patients feel better about their care.
Integration with Electronic Health Records (EHR): AI tools like PAULA connect with EHR systems such as Epic and athenahealth. They use APIs and standards called FHIR to get patient and clinical data automatically. This reduces manual data entry and makes sure requests meet insurance rules. Real-time exchange of information helps prevent errors.
Multi-channel Communication: Besides voice calls, AI platforms also offer chatbots, text messages, and portal updates. This helps teams and patients get information quickly and keeps track of the entire prior authorization process.
Dynamic Rule Engines: AI systems keep rules updated as insurance policies change. They adjust automatically without needing people to reprogram them, lowering rejections and keeping work running smoothly.
Analytics and Reporting: Many AI platforms have tools that find patterns in denials, track how often appeals succeed, and show where problems happen. This data helps leaders improve their strategies and manage authorization better.
Compliance and Security: AI agents follow strict laws and rules, including HIPAA and CMS guidelines. They use secure cloud systems to keep sensitive patient data safe during prior authorization and appeals.
Hybrid Workforce Models: Some organizations use a mix of AI agents, software robots, and human experts. AI handles analysis and follow-ups, robots do routine tasks, and humans take care of complex cases and quality checks. This combination keeps work accurate and caring.
Workflow Integration: AI platforms need to work well with current clinical and administrative systems. Linking with EHR and practice management software is important for accurate data and smooth processing.
Staff Training: Workers must learn how to read AI reports and handle exceptions the AI finds. Good training helps get the most out of the new system and builds trust.
Change Management: Leaders should support the switch to AI workflows. They must handle worries from staff and set realistic goals for what AI can do.
Performance Monitoring: It is important to regularly check how well AI is doing by tracking things like approval times, denial rates, and billing results. This helps keep improving the system and meeting organization goals.
Mayo Clinic: Their AI agent “Joy” makes insurance calls, manages follow-ups, and gives status updates. This reduces repeated work, improves accuracy, and saves time.
Metro Health System: Using AI automation, they cut patient wait times during prior authorization and onboarding by 85%, from 52 minutes down to less than 8 minutes.
Signature Dental Partners: They lowered the days it takes to collect payments by 45% using the PAULA AI agent, showing better money management.
Ottawa Hospital: AI agents handle pre-surgery appointment tasks. This saves about 80,000 staff hours every year and gives patients 24/7 access to surgery information, lowering stress and helping patients get ready.
Automated voice AI agents are becoming important parts of modern medical practice management. They help get prior authorization denials and appeals done faster and with fewer mistakes. They also reduce the amount of work for healthcare staff. In the United States, using these AI tools can lead to quicker care for patients, better financial results, and happier patients by simplifying a very difficult administrative task.
Follow-up calls are a fit for voice AI agents because payor portals often provide incomplete information, such as a denial without reasons or appeal instructions. Voice AI agents can acquire a full picture by calling payors, reducing administrative burden and improving timeliness of necessary follow-ups.
Infinitus AI agents handle checking prior authorization submission status, decision status, formulary exception status, and appeals status by calling payors, retrieving detailed information including denial reasons and appeal processes, and following up periodically until resolution.
Timely follow-up prevents treatment delays for patients and avoids revenue loss for providers. Inefficient follow-up can lead to adverse patient outcomes, as noted by AMA findings that nearly 1 in 4 physicians have seen serious events caused by prior authorization delays.
By automating routine, repetitive follow-up calls to payors regarding prior authorization status and appeals, Infinitus agents free healthcare workers from manual calls and administrative tasks, allowing them to focus on higher-value patient care activities.
When denied, the AI agents can acquire the exact reason for denial and obtain detailed instructions on the appeals process, enabling patient support teams to act quickly and efficiently on next steps.
They contact payors or PBMs to understand and follow up on formulary exception requests, check approval status, retrieve denial reasons if applicable, and provide guidance on appeal options to streamline coverage for non-formulary drugs.
Appeals processes vary by payor and often require repeated status checks. Automating these follow-ups reduces administrative work, ensures consistent monitoring, and quickly identifies if further appeals are possible or if the process is resolved.
Variable turnaround times cause uncertainty and force staff to waste time on repeated calls to payors. AI agents schedule and automate these calls, ensuring timely updates while eliminating the inefficiency of manual status checks.
These AI agents absorb the time and financial costs associated with frequent payor check-ins, reducing overhead for pharmaceutical patient support teams and minimizing risks of delays caused by administrative hold-ups.
Providers can reach out to Infinitus to learn about their voice AI agent platform, enabling automated follow-ups on prior authorizations, appeals, and formulary exceptions, thus integrating AI-driven efficiency into their administrative workflows.
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