The healthcare industry has spent the past two decades investing in and adopting technology solutions to reduce costs and improve patient care.
However, the road to payer-provider collaboration continues to be pockmarked by manually driven systems and processes that were not designed to adapt to the needs of a rapidly changing healthcare system. Automated solutions have not solved the problem due to variation in the way point-of-care solutions work and the formats being used by systems, sometimes even within the same electronic health records system.
Few processes exemplify this challenge better than revenue cycle management, specifically prior authorizations. Designed as a vehicle to manage overutilization, reduce claims denials and shield patients from unexpected bills, prior authorizations have proliferated as an overly burdensome administrative task that delays care and burns out staff, according to a survey by the American Medical Association released last year.
In May, Myndshft Technologies commissioned a healthcare market research firm to conduct a qualitative market research study focused on diagnostics labs. Among many pain points, prior authorization remained a top concern among RCM executives.
One of the survey participants, an associate vice president of revenue cycle at a global laboratory said, “Most payers now have restrictive policies on certain tests, but when you go to their website, those policies are not listed like they are under CMS. It's been a very big challenge for our revenue cycle team.”
The infrastructure that supports prior authorizations is decades behind today’s leading technologies. According to the 2018 Council of Affordable Quality Healthcare Index, 88% of prior authorizations are still submitted manually.
Providers burn through precious time, money and resources when they must submit prior authorization requests multiple times due to incomplete or inaccurate information, unexpected changes in requirements or because care had to be rescheduled.
Things aren’t much better on the payer side. In fact, responding to a prior authorization request can cost a payer as much as $80 per prior authorization.
Clearly, the process needs to be updated and improved for the benefit of all stakeholders.
Why AI and blockchain are the answer for prior authorizations
Prior-authorization processes contain several repetitive steps but also include steps that involve high levels of variation and complexity.
For example, prior authorizations cover thousands of medical procedures, and healthcare organizations are working not only with different health insurance companies but also with different types of plans (e.g., PPO or HMO). Request-and-review requirements vary by health plan and provider, too, which only magnifies the complexity.
Blockchain’s ability to clearly track and verify data and requirements is ideally suited to managing these tasks. With blockchain, payer and provider prior authorization processing information is shared electronically and standardized to the same protocols. In contrast, with electronic claims processing, supplemental information is often still shared by fax.
Meanwhile, artificial intelligence is the perfect solution to handle high levels of information-driven variation and complexity. AI can be leveraged to monitor and refine processes and make predictions to achieve even greater efficiencies.
AI has the potential to transform prior authorizations into an entirely patient-centric process. AI can mine data from lab, medication and claims data to recommend appropriate actions to preempt claim and prior authorization denial risks.
A 21st-century update for RCM processes
The success of any collaboration between payers and providers is only as sustainable as the infrastructure that supports it.
Combining AI and blockchain on a single technology platform across point-of-care solutions has a strong potential to eliminate manual steps within data-intensive processes.
AI-powered blockchain can reduce the time it takes to verify a patient’s benefits coverage, calculate his or her out-of-pocket financial responsibility and submit a prior authorization from days to a fraction of a minute. It provides time and cost savings that benefit both payers and providers.
Healthcare’s RCM processes are in dire need of a 21st-century update that delivers greater automation and real-time transparency. AI and blockchain will play key roles in that journey.
Ron Wince is the founder and CEO of Myndshft Technologies in Mesa, Ariz. An engineer by training, he has two decades of experience automating and optimizing time-consuming healthcare administrative tasks and has held executive positions at leading financial, manufacturing, outsourcing, and customer experience companies.