Prior authorizations, a critical tool of utilization management, are necessary for establishing checks and balances in the healthcare system. Unfortunately, too many providers and health plans consider the prior authorization process, which relies heavily on manual interventions and analog technologies, burdensome and a potential impediment to timely patient care.

The complexities of prior authorizations make automation and the application of artificial intelligence difficult for several reasons, including:

• Every health plan has its own policies and processes for prior authorizations, which can vary by procedure, provider, and even patient.
• Healthcare’s inconsistent data standards challenges provider integration and automation across multiple health plans.
• The clinical data from the longitudinal patient record required for medical necessity review are trapped in different information silos.
• Patient variability, based on such factors as age, disease states, treatment response, and comorbidities, creates complexity in determining whether an individual meets the medical necessity criteria and poses the most significant challenge to the prior authorization process.

With so much abrasion associated with this transactions, this is an essential conversation to understand how providers and health plans can work more effectively collaborate to facilitate prior authorizations ar speed and scale.

Additional Content

Learn more how Availity is applying artificial intelligence to increase the speed and accuracy of prior authorizations HERE.

Learn more about Availity’s approach to artificial intelligence HERE.

Thoughts? Guest suggestions? Email us at [email protected]

This episode of “Availity On-Air” was produced by Availity LLC. Research by SVM Public Relations & Marketing Communications. Our editor is Kevin McDonald. The show’s production team also includes Travis Froehlich, and Derrick Nevado.