The healthcare industry is constantly evolving, and recent news about insurers rolling back authorization requirements has been met with optimism. While this step forward is undoubtedly positive for healthcare providers and patients, it is essential to acknowledge that insurers still have a long way to go in streamlining processes and reducing administrative burdens. A comprehensive approach to process improvement and automation is required to enhance outcomes within the healthcare ecosystem.
Conquering data problems with tech:
With the Rise of AI, What IP Disputes in Healthcare Are Likely to Emerge?
Munck Wilson Mandala Partner Greg Howison shared his perspective on some of the legal ramifications around AI, IP, connected devices and the data they generate, in response to emailed questions.
Insurers face a significant challenge in managing vast amounts of unstructured healthcare data. This can lead to time-consuming manual data entry, lengthy analysis processes, and increased costs. To address these issues, insurers can leverage the power of Artificial Intelligence and Machine Learning (AI/ML). AI/ML technologies enable the efficient processing of unstructured healthcare data, automating data entry and analysis and providing actionable insights. Insurers can focus more on improving patient care and decision-making by reducing the manual efforts and time required for data processing.
Automating workflows to mitigate administrative burdens:
Administrative burdens pose a significant challenge for healthcare providers, often consuming valuable time and resources that could be dedicated to patient care. Automating workflows and streamlining processes are essential steps toward alleviating these burdens. By adopting best practices in automation, insurers and providers can optimize their operations, minimize errors, and reduce redundant tasks. Best practices include ensuring the “next best work” is presented to each staff member, according to their training, and automating the capture of each review. Hence, clinical staff has transparency into prior determinations and automated “front door” responses that immediately notify Providers of the need for additional clinical documentation. These best practices allow healthcare professionals more time to deliver quality patient care, improving the overall patient experience.
When the context of the prior authorization request requires a benefit limit exception, additional steps are required to further review the patient’s medical history as well as the current request. Common examples, such as extending physical therapy visit limits to accommodate multiple diagnoses in a year, could easily be adjusted with guided workflows that eliminate or further streamline the review process.
A Personalized Approach to Medication Nonadherence
At the Abarca Forward conference earlier this year, George Van Antwerp, managing director at Deloitte, discussed how social determinants of health and a personalized member experience can improve medication adherence and health outcomes.
In addition to payer-focused automation, provider-facing real-time review of requests that guides request submission and eliminates unnecessary requests for additional documentation will provide both provider and patient peace of mind that the services are approvable. Pre-submission can eliminate eligibility issues and focus energy on accelerating the review for alignment with medical and clinical best practices and streamline the scheduling of services in an already over-capacity system. Care coordination rules run at the point of prior authorization submission, e.g., looking across co-morbidities to identify redundant needs for the same lab tests, enabling providers to automatically access previous test results and engage more deeply with their patients, optimizing patient time in professional care, and improving care collaboration.
In addition to reviewing prior authorization approvals, organizations find themselves challenged to detect potential misuse or fraudulent requests. Many organizations have established small teams to review requests after processing them to catch illicit activities to combat this. In many of these organizations, 99% of transactions examined resulted in verifying that the request was appropriate and valid. However, deploying pre-approval learning models within available technology solutions allows organizations and staff teams to prioritize reviewing requests more likely to require follow-up investigation.
The role of collaboration in driving innovative solutions:
Streamlining healthcare insurers’ processes requires collaboration among industry stakeholders. Insurers, providers, and technology solution providers must work together to identify areas within the healthcare delivery system that can benefit from automation and process improvement. All parties can collectively drive innovation and create transformative solutions by taking an end-to-end approach. Collaboration enables the development of systems that improve the patient experience, cut costs, enhance operational efficiency, and drive better outcomes across the healthcare ecosystem.
While the recent rollbacks of authorization requirements by insurers are a positive step forward, there is still work to be done in streamlining processes and reducing administrative burdens in the healthcare industry. Adopting a holistic approach to process improvement and automation, leveraging AI/ML technologies, and fostering collaboration among stakeholders is critical to achieving enhanced outcomes. By embracing these strategies, insurers and providers can create a more efficient, cost-effective, patient-centered healthcare ecosystem. Together, we can drive industry transformation and positively impact healthcare delivery.
Photo: alphaspirit, Getty Images
With more than two decades of experience building strategy, GTM, and growth for payer, provider, medical device, and technology organizations, Susan Taylor, Pega's Vice President of Healthcare and Life Sciences, is responsible for leading the development of Pega’s innovative approaches that enable organizations to transform the administrative work of healthcare to empower healthcare teams and patients to improve health outcomes at scale.
