Prior authorization is meant to make sure healthcare services are needed and cost-effective. But the process is often slow and uses lots of paperwork, phone calls, and manual data entry. A 2023 survey by the American Medical Association (AMA) found that over 90% of doctors said prior authorization caused delays in patient care. Nearly 24% reported serious problems like hospital stays and even deaths linked to these delays.
These problems cause frustration for providers and raise administrative costs. Doctors spend a lot of time handling prior authorization tasks instead of caring for patients. The process also makes patients unhappy because they must wait longer for treatment. Medical administrators have a hard time making sure staff are trained and workflows handle the many requests well.
Artificial intelligence (AI) can help by automating simple and complex prior authorization tasks. AI systems connect with Electronic Health Records (EHRs) and insurance systems to speed up data sharing and decisions. AI can gather documents, review clinical data, and send authorization requests. This lowers manual work, makes approval faster, and cuts errors.
Jeremy Friese, MD, CEO of Humata Health, says AI is an important part of changing prior authorization processes. He expects many payers and providers to use AI more as rules encourage digital methods. The Centers for Medicare & Medicaid Services (CMS) created a rule called the Interoperability and Prior Authorization Final Rule (CMS-0057-F) that pushes for digital and standard workflows.
In practice, AI tools let providers send approval requests right from their EHRs. The tools automatically collect needed documents and use prediction models to decide if approval is likely. AI can approve cases with high confidence scores and mark tricky cases for human review. Experts suggest AI only auto-approve cases with scores above 90 out of 100 to avoid wrong denials.
Many healthcare groups in the U.S. have seen good results after adding AI and automation to prior authorization. These benefits help clinical staff, administrators, payers, and patients.
Cohere Health shows how AI-driven automation affects prior authorization. Their platform auto-approves up to 90% of requests. It handles over 5.5 million requests yearly and helps more than 420,000 healthcare providers. It connects with Epic’s Payer Platform, so doctors can submit requests inside their EHRs. This removes repeated data entry and cuts provider staff time on authorizations a lot. It lowers administrative costs by about 47% and speeds up patient care by 70%.
A community healthcare group in Fresno used AI to check claims before sending them. This cut prior authorization denials by 22% and denials for uncovered services by 18%. Their staff saved 30 to 35 hours each week that would have gone to appeals and re-submissions. Medical Mutual of Ohio and OSU Wexner Medical Center also used automated prior authorization. They saw higher approval rates and shorter decision times, which saved costs and improved operations.
AI tools help doctors make better clinical decisions. This lets them spend more time caring for patients instead of dealing with paperwork. John Bulger, MD, Chief Medical Officer for Geisinger Health Plan, said AI-driven prior authorization gave helpful, evidence-based advice that improved patient care. Providers like the lighter administrative load. Cohere Health reported a 93% provider satisfaction rate. Less workload also lowers burnout, which affects 40% to 60% of doctors. This helps keep doctors working and balances their work and life better.
Using automation and AI in prior authorization makes communication better between payers and providers. Epic’s Payer Platform connects half of the U.S. health systems with big insurers like Aetna, Humana, UnitedHealthcare, and Blue Cross Blue Shield. This allows near real-time sharing of clinical data. Using standard APIs like FHIR lowers administrative work on both sides, helping patients get care faster and reducing denials.
Medical practices, administrators, and IT teams need good planning to add AI automation to workflows and keep improvements going.
It’s important to connect AI tools with major electronic health record systems. Cohere Health’s solution fits into Epic’s Payer Platform, so providers can start and track prior authorizations within their normal workflow. This causes less disruption and saves doctors’ time. Other companies like NextGen Invent focus on making sure their tools work easily with EHR systems using FHIR and HL7 standards.
Robotic Process Automation (RPA) and AI-driven Natural Language Processing (NLP) lower manual data entry and organize clinical documents for payers. Hospitals using AI for Revenue Cycle Management (RCM) saw coder productivity increase by over 40%. This shows automation helps billing and claims processing go faster and better.
AI uses machine learning to predict which requests might be denied or are medically necessary. This reduces repeated work and speeds up approvals. Staff can then focus on tough cases that need human judgment. For example, HealthHelp and Anterior’s AI system cut prior authorization approval times by 99% by automating accurate decisions.
It is good to add automation in steps, keeping humans involved to ensure care quality and ethics. At first, humans decide on complex or uncertain cases while AI handles easier approvals. Ongoing checks help AI systems improve. Jeremy Friese supports rules where only high-confidence cases are auto-approved and humans review difficult cases.
Good results depend on training administrative and clinical staff and clear communication. Providers need to see AI as a helper, not a replacement. Teamwork across clinics, administrators, and IT helps align operations and lower resistance to new technology.
AI-driven automation helps beyond prior authorization. It improves hospital operations and financial management.
More hospitals use AI to speed up billing, claims, and denial handling. Almost 46% of U.S. hospitals use AI in RCM jobs, and nearly 74% use robotic automation. AI improves billing codes with NLP, predicts denials, and automates appeal letters. This makes finances more accurate and faster. For example, Auburn Community Hospital cut cases not billed after discharge by 50% and raised coder output over 40% after adding AI tools.
AI tools help find errors and fraud faster, making audits 30% more efficient and document speed 50% faster. Cohere Health’s AI payment integrity solution got an 8 to 9 times return on investment by stopping extra payments while keeping good relations with providers.
AI systems help predict staffing needs, plan schedules, and move staff based on workload. More than half of U.S. hospitals try these tools to fix worker shortages, raise productivity, and lower burnout.
Faster prior authorization approvals mean patients get care sooner, cutting delays. Automation speeds up inpatient and outpatient reviews by up to 50%, helping healthcare results and patient satisfaction.
AI-driven automation in prior authorization is changing healthcare workflows in the United States. It can lower administrative work, improve cooperation between payers and providers, and speed up patient access to care. Medical administrators and IT managers need to understand these technologies and how to add them to improve operations and patient outcomes.
Epic aims to reduce clinician documentation burden, streamline charting and coding, and deliver evidence-based medical insights directly at the point of care to improve clinical workflows and patient outcomes.
ART automatically drafts responses to patient messages, saving clinicians about half a minute per message, generating empathy in communication, and improving patient satisfaction by providing timely, human-like responses.
AI-powered charting captures patient encounters via ambient voice technology, producing notes instantly, thereby reducing documentation time, alleviating clinician burnout, improving work-life balance, and helping retain clinicians in practice.
Epic is working on over 100 AI capabilities including auto-adverse drug reaction tagging, patient-friendly report summaries, billing coding assistance, explain-my-bill agents, automatic order and diagnosis queues, and automatic specialty form population.
This AI tool analyzes treatment outcomes from similar patient profiles to recommend evidence-based therapies, helping clinicians select optimized treatments, potentially improving adherence to evidence-based medicine which is currently low.
Cosmos, with 270 million patient records, supports tools like ‘Look-Alikes’ that identify patients with similar rare diseases and enable physician collaboration, enhancing diagnosis and treatment for complex cases.
Epic collaborates with Microsoft to optimize AI compute costs (cut in half since last year) and offers an open-source AI validation tool for health systems to test and monitor AI models, supporting compliance and affordability.
Epic’s payer platform automates prior authorizations, reduces denials, improves care access speed, and decreases workload for both providers and insurers by streamlining data access and authorization processes.
Epic is developing AI-generated patient-friendly report summaries and ‘explain my bill’ agents that translate complex medical information and billing details into easily understandable language to enhance patient engagement and transparency.
Epic’s Aura platform integrates genetic testing and medical device data, including wearable health monitors, directly into clinical workflows, simplifying access to critical diagnostics and enabling faster diagnosis and intervention.
Simbo is using AI agents to automate all phone related workflows. Connect now to know more.
Schedule AI Agents Demo Now© Since 2019, Simbo AI.
