The title of the new report says it all: ‘Exhausted by prior auth, many patients abandon care: AMA survey.’ But what can payers and providers do to cure patient exhaustion? [1]
Diagnosing the problem
The answer, in short, begins with speeding up a process slowed down (ironically) by technical innovations in the decades since the digital revolution came for the healthcare industry. The digital tools at the disposal of payers and providers, including electronic medical records, were not designed with the goal of interoperability. As a result, the record-keeping technologies essential to the prior auth process evolved along separate, parallel paths.
It’s important to acknowledge how this gap, and the lack of shared data sources, created headaches on both sides of the payer-provider aisle. The AMA survey focused on physicians, who rely on prior authorization to offer medically necessary care. A remarkable 95 percent of physicians who responded to the survey feel as if prior authorization increases their burnout levels, but the process has unwanted consequences for all parties involved.
Health insurance companies are frequently burdened by delays in receiving forms, a byproduct of a complicated system and antiquated technology. Patients obviously want the care they need as soon as possible. Unfortunately, as the cost of specialty drugs rises — such as CAR-T Cell Therapy, which can be lifesaving for cancer patients who failed previous treatment — the process is delayed further because payers’ level of scrutiny increases.
The heart of the issue today: a pervasive payer-provider friction. This has been almost accepted as status quo in the healthcare industry, as most payers and providers aren’t on the same page with shared data sources.
Solutions
Innovations in the AI space are speeding up both prior and concurrent authorization processes within and between provider and payer organizations, but need to be applied in a responsible manner. As in any industry, humans must have the ultimate agency over use-cases of AI. Applied carefully, these AI tools can be used to accelerate the decision-making process in both prior and concurrent authorization in a way that’s fair to the patient, payer and provider. Getting the payer and provider on the same page, in partnership, is the challenge; the technology already exists.
For example, as soon as a patient’s electronic health record is updated to include a recommended procedure, an AI script can instantly review whether prior authorization is needed. If it’s flagged, each prior authorization case can be compared against similar claims in the past to instantly determine whether approval was ultimately reached. As long as the payer and provider agree to the standards beforehand, this can streamline and accelerate the process by eliminating some of the work historically performed by humans.
Importantly, in this use case, AI doesn’t replace human oversight. Instead, it pre-filters claims. Those clearly necessary based on pre-defined criteria, those clearly unnecessary, and the gray areas requiring human expertise are sorted automatically. For claims that have more clear-cut outcomes, both parties will already have insight into the “why” and “how” any agreement was reached. For those cases that did not gain approval, AI will provide insight into the “why not.”
As evidenced at this year’s AHIP, payers are looking for more innovative ways to leverage AI as a means to not only comply with the Final Rule, but to build trust via more data transparency between payers and providers. [2][3] The Final Rule legislation effectively forces more collaboration into the prior authorization process, with shared access to clinical information — updated in real-time and transmitted electronically — a practical necessity.
By 2027, payers must implement API technology to automate prior authorizations and exchange information with patients, providers, and other stakeholders. In some places, this transition is already happening today for concurrent authorization processes as well. Payers can position and prepare themselves for a healthcare industry that relies upon a higher standard of trust, communication, and collaboration in its everyday processes. Building this trust takes time.
The abandonment of care by patients is a critical challenge, particularly in cases of life-threatening cancers being left untreated, but there are solutions already in use that can speed up prior authorizations and thus minimize care delays for patients.
Reference
[1] Henry TA. Exhausted by prior auth, many patients abandon care: AMA survey. Online. JAMA Network. July 18, 2024.
[2] Tong N. AHIP 2024: Not just a buzzword—payers envision AI’s future. Online. Fierce healthcare. Jun 18, 2024.
[3] CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process. CMS.gov. Online. January 17, 2024.
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DOI:10.14229/onco.2024.08.06.001
