AI in Healthcare Could Revolutionize the Pre-Authorization Process

AI in Healthcare Could Revolutionize the Pre-Authorization Process

More than nine in 10 physicians say that pre-authorization programs have a negative impact on patient outcomes, according to a 2017 survey by the American Medical Association (AMA).

While insurers tend to authorize most requests, the process can be unwieldy – an administrative fiasco of recurring paperwork, phone calls and bureaucracy that can slow a patient’s access to care.

According to the AMA survey, which examined the experiences of 1,000 patient care physicians, 64 percent reported waiting at least one business day for prior authorization decisions from insurers and 30 percent said they waited three business days or longer.

Wait times for pre-authorized medical care have consequences for patients. 92 percent of the physicians surveyed said that the prior authorization process delays patient access to necessary care; and 78 percent reported that prior authorization can sometimes, often or always lead to patients abandoning a recommended course of treatment.

Imagine the efficiencies that could be achieved if the manual workflow of pre-authorizations could be lifted and replaced with automatic approvals that rely on artificial intelligence (AI) healthcare solutions.

For example, lab, medication and claims data can be mined. This information could be analyzed in a way that even before a physician recommends a course of action, the treatment would already be approved, streamlining the payer-provider collaboration. This process would be based on showing payers the improved health of certain types of patients who previously received a specific treatment option to address their medical condition.

Once payers bought into using AI for pre-authorizations, it could conceivably eliminate all of the administrative work between primary care providers, specialists, and payers. It would be an entirely patient-driven process that would rely on categories already built into the AI models and approved by payers.

Recognizing the administrative burden of pre-authorizations, payer and provider organizations are committed to improving the process. So now is the time to explore the potential of AI in this area. It won’t happen overnight, but it certainly is possible within the next few years. And as the digital age advances and cutting-edge artificial intelligence solutions change the health care landscape, automated pre-authorizations may become less of a pipe dream for medical administrators and more of a reality.