How HCSC is using AI to speed up prior authorization

Of the many tools that payers use to control costs, prior authorization ranks high on the list of what providers and patients find particularly vexing.

However, Health Care Service Corporation hopes to fine-tune the process using the power of artificial intelligence.

Monica Berner, M.D., HCSC’s chief clinical officer, said in a press release that the company “recognized a few years ago the need to make it quicker and easier for providers and members to get the answers they need and took advantage of emerging technology to develop a suite of tools that simply work better for everyone involved.”

The company’s use of augmented intelligence allows it to process prior authorization requests about 1,400 times faster than before, according to the press release. HCSC covers about 18 million members in Illinois, Montana, New Mexico, Oklahoma and Texas. The company received about 1.5 million prior authorization requests in 2022.

The tool was first developed in 2021 and then used in a pilot the following year that focused on specialty pharmacy and behavioral health. Speedy approvals were granted 80% of the time for behavioral health services and 66% for specialty pharmacy requests.

“By triaging and approving requests that require minimal information, the technology frees up clinical staff for review of more complex requests,” according to the press release. “No prior authorization requests are denied using the tool—they are only approved or advanced to a hands-on review by an HCSC clinician.”

Thanks to the results, HCSC expanded the program to include prior authorization requests from skilled nursing facilities, inpatient and outpatient hospice care, inpatient acute care, long-term acute care, home health and outpatient services.

“The prior authorization tool streamlines the submission process and provides auto-approvals when critical criteria are met,” the press release said. “By asking providers the precise number of questions required to evaluate and expedite claims, it helps ease the administrative burden on providers and their staffs—taking six minutes, on average, to submit a request.”

HCSC also deploys an algorithm that mines historical prior authorization approvals to make it easier to approve treatment within seconds.

“The AI technology is used for 93% of HCSC members for a limited number of procedure codes,” according to the press release. “The company’s next phase will involve expanding the number of codes included. With this technology, no requests are denied without a human in the loop.”

The technology builds on HCSC's 2018 decision to eliminate prior authorization for about 1,000 procedure codes. Berner said in the press release that fixing “prior authorization so it works better for everyone isn’t a new idea and we’re happy to see others in the industry moving in that direction as well.”

In January, the company launched a “gold card” program in which nine selected provider facilities that demonstrate they follow generally recognized best practices can have their prior authorization requests approved within three or fewer days for an inpatient procedure.

“In 2022, more than 14,000 prior authorization requests were auto-approved for the nine facilities currently participating in the program,” the press release states.