Are you faced with tremendous pressure to improve margins while also improving patient outcomes?
It’s no secret that current prior authorization (PA) processes are known for being labor intensive, time consuming and costly. Cost, technology, data, analytics, member acquisition and provider relations are the lifeblood of your organization, yet still for many, automation to reduce expenses without sacrificing patient care is not a top priority – why not?
Did you know?
The hardest part of automating back office prior authorization is evaluating medical necessity.
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Cost per Case
Could range from $13.17 to $26.37 per initial case reviewer.1
Administrative Costs
- A study has shown that administrative costs in 2017 totaled $274.5 billion, representing 9.6 percent of total expenditures by insurers and other third-party payers and 7.9 percent of national health expenditures.2
- Annual fully loaded cost of one FTE clinical case reviewer: $82,500.3
- Many health plans may not factor in the heavy administrative expenses that come with poor communication with providers, which results in time spent resolving errors that are avoidable.
Antiquated Technology & Limited Data
Accessing data through disjointed data sets and systems restricts the ability to consume high-quality clean data, which is critical, yet very difficult to obtain. This prohibits payers from making informed care decisions due to too much variability. The impacts are large amounts of manual processes, possible discrepancies and lack of data-driven insights which continue to increase healthcare expenses.
Real-time Medical Necessity Determination
Annual Spend Reduction
Help reduce administrative expenses and your PMPM to as little as $0.10.
Smart, Innovative Technology
Use NLP and ML to unlock unstructured data, codifying complex medical guidelines to enable clinical indications, structured facts, relational logic and clinical decision support.
Real-time Approval
Validate a patient’s eligibility and clinical necessity to minimize the need for human review.
Actionable Data
Query on all approval and provenance (sub-level fact) data allowing for a transparent decision trail for auditing purposes and future research.
How it Works:
Automating prior authorization in the payer back office is no longer enough; there is a need to have insightful and actionable information at the point of care. In the race to provide the most efficient and appropriate care, there is an increasing need to have real-time and predictive information within the clinical workflow.
There are a growing number of companies automating eligibility, verification and site selection. The growing trend and where we excel is in providing real-time, point-of-care medical necessity decisions to answer the question, “Does the service requested meet medical necessity?”
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Resources
Automated Electronic Prior Authorization
For Patients, Providers and Payers
Driving Value:
Automating Prior Authorization at the Point of Care
Smart, Fast, Efficient:
Introducing Seamless Patient Care