The Automation of Prior Authorization Submission

Administrative tasks can be prominent, frustrating time-sinks within any career. They often don’t directly relate to the job, but rather allow the job to happen. There are few industries where administrative work is as prominent as the healthcare industry. It’s vital for patients to be kept safe in a range of ways. This is why patient files are managed very carefully, and typically, slowly.

However patients and those in need of care aren’t the only group of interest. Insurance companies are another massive force which healthcare workers need to appease. The challenge in satisfying insurance companies is that their first concern is not patient well-being. One example of this in practice is the process of submitting prior authorization.

Prior authorization is when a healthcare provider has to request approval for an insurance plan to cover a procedure. Most insurances cover a basic range of services, but certain prescriptions or procedures can fall outside that. On the surface, this is something that saves insurance companies time and resources. It would be impossible to specify every type of medical treatment and how it is covered under insurance.

Where prior authorization goes wrong though is when patients are in need of urgent or life-saving care. Now the process of the healthcare provider submitting and gaining approval can be life-defining. Prior authorization leads to care being delayed 100% of the time, and hospitalization 25% of the time.

This issue is made even worse when the process is often tedious and inexact. Calling insurance companies, retrieving patient files, and submitting the request all take time and can go wrong. All of these factors together have led to the development and importance of  prior authorization process automation.

Allowing an AI-based program to retrieve the files, make the calls, and submit the requests saves countless hours and dollars. Currently 35% of healthcare providers hire staff to deal explicitly with prior authorization. Not only does this create an alternative for those without the funding necessary for new staff, but it works 24/7.

This is important because prior authorization requests are commonly refused, even without good reason. Having an automated service which can submit appeals to rejected requests is vital. It can make the difference in life-saving care being given the day of, or the day after. Insurance is what allows anyone in the U.S to afford the care they need. 

Prior authorization isn’t just a matter of saving some money on a procedure, it’s what allows a procedure to happen. Automating the process is something that healthcare providers are eager to see in action. After all, prior authorization acts as a barrier to giving care, a barrier that keeps providers from doing their job. Making that barrier as insignificant as possible is the only way forward.

Prior Authorization Automation
Source: Orbit Healthcare

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