The Case for the Electronic Prior Authorization

WEBINAR: Interested in automating Prior Authorizations? Be sure to register for our upcoming webinar Using AI to Automate Prior Authorization Processing (October 28 @ noon CST – Register HERE).

The American Medical Association (AMA) is working aggressively to make electronic prior authorizations a national requirement. There’s good reason. An AMA survey of 1,000 practicing physicians in December 2019 found that:

• 91% of physicians reported that Prior Authorization (PA) delays access to necessary care.
• 24% of physicians indicate that PA has led to a serious adverse event for a patient in their care.
• Practices report completing 33 PAs per week.
• The workload takes almost two business days’ worth of physician and staff time.

It’s hard not to agree with the AMA. However, electronic PAs will require both houses of Congress to agree and pass legislation mandating electronic PAs. In the midst of a global pandemic, economic collapse, multiple natural disasters and election year kerfuffle, Congress is unlikely to pass anything soon.

What we need is a solution that will help patients, providers and health plans now, while Congress focuses on trying to find its belly button.

What would an Ideal Solution look like?

So what can we do, now? Well, an ideal solution might look like this:

1. Providers would keep doing what they are doing today, helping patients and faxing PAs to health plans. This requires no new technology to be purchased for cash-strapped physicians and no change in their current processes or technologies. They can focus on healing people.
2. Health plans would have software that automatically “reads” the faxed PAs. The software would also separate faxes for different patients that were faxed together from the same provider (a big problem today).
3. The software would then identify what type of documents are included in the fax.  These typically include faxed cover pages, prescriptions, lab results, medical history and other clinical documents. Software, with the help of Artificial Intelligence (AI) would do the identification.
4. The software would then extract key information from each fax page. Data such as patient name, date of birth, dates of service, procedure codes, diagnosis codes and other important information could be “read” from the faxed images and turned into data as if it had been typed into a keyboard.  Even handwritten data could be read.
5. Finally, the PA data would then be automatically shared with multiple systems and immediately routed via automated workflow to the right person (a nurse or doctor) at the health plan who can review the case and complete the approval.

The Ideal, Realized

As it turns out, this software exists today.  It is called Intelligent Capture software.  In fact, many of the components of Intelligent Capture have been around for 20+ years. You have probably heard of Optical Character Recognition (OCR), Artificial Intelligence (AI) and Enterprise Workflow (Workflow) software.

• OCR software has been extracting data from documents for over 30 years.  Even handwriting recognition has a long history of success.
• Artificial Intelligence algorithms, including machine learning, power much of the software on the internet, especially applications like social media.
• Workflow software has routed data and digital images around our offices for many years as well.

Combining OCR and AI is what makes Intelligent Capture so powerful. Very capable of automating the reading of a complex PA.  Combine Intelligent Capture with Workflow and you can automate much of the pain of the current PA process today

Let’s face it, the AMA is right. Electronic Prior Authorizations are the best long term strategy.  However, we can solve the problem with existing technology at a fraction of the cost and without requiring physicians to spend money they don’t have, change their processes or buy new technologies. We can also don’t have to wait for an act of Congress.

Prior Authorization Innovation Proof of Concept

It is reasonable to be skeptical that Intelligent Capture and workflow software can automate PAs at a fraction of the cost of current technologies.  That’s why we created the PA Innovation Proof of Concept project (IPOC).  The IPOC is a 30-day project to test your PA documents with Intelligent Capture software. We offer the IPOC in a short timeframe and at a low cost to show you what is possible in just 30 days.  The technology works, the PA Innovation POC simply proves it to you, with your documents, before you invest in a complete system.

Schedule a Call

If you would like to learn more about the BRYJ Innovation POC for Prior Authorizations, please reach out to me at mike@bryjinc.com. Thanks.

Mike Hurley is co-founder and President of BRYJ, Inc. BRYJ, Inc. is a consulting and systems integration firm on a mission to help organizations with intelligent capture and digital transformation. Our team has been helping companies digitize their processes since 1997. You can follow Mike on Twitter @BryjMike. Or connect with him on LinkedIn here.