Problem
Surgery pre-authorization is increasingly complex. This complexity slows the efficient provision of timely patient care. This challenge is partly driven by payors’ documentation requirements and providers’ insufficient documentation. Manual processes to resolve these challenges have become labor intensive, especially for the Orthopedic surgeons, administrative staff, and PRMO staff.
Solution
We are implementing an AI solution to streamline the surgery pre-authorization process in the Department of Orthopedics. This AI tool automatically identifies and outlines the necessary documentation criteria for surgery authorizations, reducing the likelihood of missing critical elements, minimizing delays in patient care, preventing administrative errors, and mitigating revenue loss. It would also free up healthcare providers to concentrate on direct patient care.
Our first step was to identify prior authorization criteria for spine and arthroplasty plans and assessments submitted to insurers. When an orthopedic surgeon or revenue manager selects a signed note for AI application review, it checks the note for completion of the criteria. The user can quickly read a checklist and related reasoning.
Impact
The impact of this solution is substantial. It can streamline surgery authorization and enhance technology integration, resulting in more efficient processes. This will improve patient care, reduce cancellations, and increase operational efficiency. The collaborative effort involving DIHI, DHTS, PRMO, Duke Compliance Office, DHIP, and the Department of Orthopaedics promises to streamline healthcare processes, leading to a transformative impact across Duke University Health System.
