Health Plan Automates Prior Authorization Process Using AI

Guidewell, the parent company to health plan Florida Blue, has partnered with an artificial intelligence company to automate the prior authorization process.

Florida Blue will become the first payer to apply automation to prior authorization approvals in an attempt to expedite the process and improve patient and provider satisfaction.

The solution will leverage artificial intelligence resources from the automation company Olive.

“Olive’s AI platform helps GuideWell create a best-in-class utilization management model that reduces the administrative burden on our providers while creating a better experience for our members,” Elana Schrader, MD, senior vice president of healthcare services and president of GuideWell, said in the press release. “By being the first health plan to automate approvals, we are leading the way for insurers to close the technology gap to better serve our members and providers.”

The tool aims to eliminate the delay that can accompany prior authorization requirements by moving the process to the point of care, according to the companies. Individuals may receive a required authorization from GuideWell before they leave their provider’s office.

Through artificial intelligence-powered clinical reviews, the tool can determine if the health plan will cover the needed services almost immediately, the organizations said.

Physician practices tend to experience high administrative burden from prior authorization requirements, as they usually require multiple phone calls and faxes between the provider and health plan. The process can be time-consuming and lead to care delays if the data submitted is incomplete or inconsistent.

Payers also face the strain of prior authorization. GuideWell’s health plan companies receive hundreds of thousands of prior authorization submissions, the press release noted.

The new automation solution has the potential to help relieve this burden and allow providers to spend less time on administrative processes and more time caring for patients.

In 2021, GuideWell launched a pilot program in Florida using the automated prior authorization process. When immediate responses were available, the technology reduced the waiting period by 10 days and led to 48 percent faster decisions. In addition, there was a 27 percent decrease in unnecessary prior authorization requests.

The health plan will begin deploying the artificial intelligence platform in April, with plans for a full-scale implementation in July.

Prior authorizations remain a top concern for hospitals and physician practices, even as facilities face COVID-19-related issues.

Data from the Medical Group Management Association (MGMA) revealed that prior authorization requirements were the top regulatory burden for medical group practices in 2021.

A recent survey from the American Medical Association (AMA) found that 88 percent of physicians reported that prior authorization generated high or extremely high burden, with physicians completing an average of 41 prior authorizations each week.

Further, the survey revealed that prior authorizations frequently delayed access to necessary care for patients or led patients to abandon their treatment altogether due to the waiting period or other prior authorization issues.