Problem
Prior authorization (PA) poses a large administrative burden spanning all aspects of the health care system. This administrative burden contributes to large costs to the health system, delays in care, worse health outcomes, and physician burnout. Protocols, timelines, and requirements vary across payers, particularly concerning PA requests, reviews, approvals, and communication. Therefore, requirements often have to be individually abstracted, packaged, and communicated to differing payers.
Solution
Utilize artificial intelligence to automate the retrieval of data and prepare a prior authorization request. We propose to start with a prototypical medication example. Currently, when one of the proposed prototypical medications is requested, a human sends clinical information to the payer in the form of progress notes, radiology studies, and laboratory results. However, there is no packaging of this information by pulling out the relevant information for the payer.
Impact
This innovation will decrease the volume of this denial type significantly and reduce the number of staff required to process these denials. We also expect that physicians and PA staff will experience a decrease in the time and administrative burden associated with these authorization submissions and there will be an improved patient experience and health outcomes.
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