Why is AI the future of prior auths

Ajish Prakash on January 21, 2019

In the healthcare industry, artificial intelligence has gone a long way from being just an idea to a total game changer. There has been a lot of research put into the applicability of Artificial Intelligence in the medical industry. It looks like Artificial Intelligence has great prospects for a great number of applications such as the reduction of unwarranted surgical variation and highly complex health management programs for a large population.

Anyhow, a number of powerful arguments have been made according to which we can see some great transformative results by using Artificial Intelligence in the administrative and business end of healthcare. This, according to the arguments, may allow health plans and provider organizations to enjoy quick results. One example would be the optimization of the process of prior authorization. ‘

Over the last decade, prior authorization has been really necessary. This is primarily because prior authorization ensures that the healthcare services are not being overutilized and that particular care being provided is entirely appropriate.

A survey conducting by the American Medical Association states that around 84% of the providers think that prior authorization is ultimately a burden. At the same time, 91% of providers think that they happen to have a negative impact on patient outcomes. Moreover, 71% of them claim that it takes up to three to four days to receive responses to the prior authorization requests.

Over here, the most painful point is not the concept of prior authorization itself. Rather, the manual processes that are used to obtain or request them are the main pain. Based on a CAQH Index annual report published in 2017, around 82% of the prior authorizations involve manual processes. According to this report, fully automated and electronic prior authorizations have not been adopted at large. Only about 85 of these are fully automated.

On the other hand, if artificial intelligence is used for the prior authorization processes, the providers and health plans may be able to save several billion dollars. Despite this, artificial intelligence in the healthcare industry remains a mystery that which many feel intimidated by.

At the core, artificial intelligence is nothing but automation of a process involving intelligence. Once a task gets completed, the system evaluates the outcomes and the process gets refined based on the past experiences. This is exactly the same way in which a human brain learns. Although, the difference lies in the fact that artificial intelligence systems are able to accomplish this task on a very wide scale in a shorter amount of time. This would be far beyond the scope of a human brain.

There are a number of components in a prior authorization process that is repetitive in their nature. However, some processes are extremely complex and include a lot of variation. The complex and repetitive tasks are ideal artificial systems as they are capable of monitoring the outcomes, and refining the processes with better predictions over time. Artificial intelligence indeed shows great prospects for prior authorization and carries the potential of turning it into a patient-driven process in its entirety.

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