Despite all the automation innovations that exist today—Robotic Process Automation (RPA), Machine Learning (ML), and Artificial Intelligence (AI)—prior authorization automation remains a complex challenge with a myriad of disparate payer and plan-specific procedures and processes.

Many organizations have invested countless hours and financial resources in authorization automation technology, only to realize the juice wasn’t worth the squeeze. Despite the good intentions of numerous technology vendors attempting to automate prior authorization functions, access to standardized electronic authorization transactions is still very limited.

The most prevalent technology in use today for authorization automation employs the use of “bots,” which are basically computer scripts or routines developed using RPA. Think player piano. Bots emulate a user performing manual authorization functions, such as searching a payer portal or website to determine if a procedure requires prior authorization based on the insurance payer and plan-specific rules. Other common processes bots can perform include authorization requests/submissions through a payer’s online portal, inquiries to check the status of previously requested authorizations, and other similar functions.

Challenges with prior authorization automation

Although the industry has recognized some success utilizing these technologies, many gaps still exist that require human intervention. Portals often utilize decision trees to determine if a procedure is medically necessary or if it is the best or next logical procedure in the diagnostic or care continuum. These situations often require human intervention, thus reducing the effectiveness of the technology. Often, clinical documentation or medical records are requested. Though some of these requests can be automated using bots, entire medical records are often submitted, requiring payers to sift through and locate the pertinent information, potentially resulting in approval delays.

Payer connectivity is another challenge that limits authorization automation. Only a handful of payers support the EDI X12N 278 transaction set, even though it was mandated within the ACA and required payer adoption by Jan. 1, 2016. Bots require consistency to perform properly. Changes to websites and portal pages, user login credentials that expire, and MFA (multifactor authentication) often create challenges. Some payers explicitly prohibit the use of bot technology, fearful that bots may overload their systems or cause other unforeseen problems.

Increasing revenue and improving the patient experience

At Change Healthcare, we recognize and acknowledge these challenges. We optimize medical authorization management by leveraging expert staffing, innovative automation, and broad connectivity. Our Connected Authorization Services solution takes advantage of the technologies where we can and utilizes people to perform other tasks necessary to determine need and obtain prior authorization approval. The result is full automation of prior authorization tasks for the accounts assigned to us.

Our recommended approach is to assign high-volume, low-complexity authorization tasks to Change Healthcare to manage and then allow your staff to utilize our technology to supplement their efforts on other authorization tasks. This allows healthcare organizations to reallocate staff, filling staffing voids that may exist. Long term, when the payer connectivity and technology catch up, the organization can bring everything back in house and utilize the expanded technology themselves.

Our goal is to provide technology to facilitate a no-touch prior authorization automation process. Imagine a technology platform that has the intelligence to determine when prior authorization is needed, can determine if one is already on file with the payer, predetermines the clinical decision support criteria the payer will use, and submits all the information the payer needs upfront with the initial submission. This will set the payers and providers up for success, helping to increase revenue, and improve the patient experience.