3 ways AI and automation improve utilization management

July 28, 2021

Healthcare system costs have been growing out of control for years now, and utilization management is one key way payers and providers ensure appropriate care is being delivered cost-effectively. Utilization management, or UM, is the evaluation of appropriate medical care according to evidence-based criteria and health payer guidelines. The purpose is not only cost containment, but also providing patients with the best and most suitable care — from reduced length of stay to improved discharge planning. For payers, once their rules and guidelines are established, the utilization management process revolves around managing prior authorizations submissions through clinical and peer to peer reviews.

UM processes directly impact payer financials, case management and their health plan member and provider satisfaction. When utilization management is inefficient, it leads to frustrating care delays and increased operating expenses for the health insurer. However, typical UM solutions place member and provider satisfaction and cost containment at odds. More rules or more thorough review processes can reduce the high costs of medical services, but end up hurting the member and provider experience. It’s always been a trade-off. Until now.

Now, payers have the opportunity to transform their UM processes by leveraging automation through artificial intelligence. By implementing an AI utilization management solution, payers can simultaneously improve their member and provider experience while decreasing operating expenses and medical costs. It’s a win-win. Here are three ways to get started:

1. Automated prior authorization approvals

Unlike simple robotic process automation (RPA) solutions that only automate specific parts of the prior authorization process, AI can fundamentally change the way reviewers process prior authorization requests. With artificial intelligence, payers can connect directly to provider EMRs to pull clinical information, enabling automated utilization reviews and approvals. When a healthcare provider submits an authorization request, AI pulls relevant information from the patient’s clinical documents directly from the EMR and then checks this information against the medical necessity criteria to ensure the patient receives the right care. If all criteria are met, the request can be automatically approved, without a utilization management reviewer ever touching the prior authorization and alleviating the need for a clinical review. This can speed up the average approval from weeks to hours.

2. AI-assisted clinical reviews

Automated approvals turn the authorization process into “authorization by exception.” Instead of every request requiring manual approval to determine the appropriateness of care, only those that AI can’t automatically approve get sent to a human UM reviewer. Plus, even when a request can’t be automatically approved, artificial intelligence’s assistance doesn’t stop. Working as an AI sidekick, it guides the UM reviewer during the clinical review process. It works as a desktop-based assistant, automatically displaying the relevant medical necessity criteria and verifying the necessary patient information. AI-assisted clinical reviews save employees time and enable faster manual reviews.

3. Point-of-care authorizations

Imagine if provider EHRs (electronic health records) and payer care management platforms were seamlessly connected using the same technology. They could communicate and automate processes like never before, improve decision-making, and deliver high-quality care, all while reducing healthcare costs. Well today, this is officially a reality using Olive. Olive is an artificial intelligence solution that is already in hundreds of hospitals around the country and now supports payer platforms as well. What does this mean for providers and payers? By automating at both ends of the fax machine, Olive supports fully automated prior authorizations, including the ability to provide authorizations at the point of care. A large private insurer has already shown that it truly is possible and has revolutionized the way prior authorization approvals are done.

A provider can order a procedure or treatment in the EMR at the point of care while communicating with the patient about their care plan. AI can take over from there, checking to see if the health insurer covers the order and/or if a prior authorization is required. If a prior auth is required, it can use the same automated approval process discussed previously to pull patient clinical documents, check medical necessity criteria and automatically approve the order. This can all be done automatically, eliminating delays in patient care. The patient can leave the appointment knowing the next step in their care plan and schedule their next appointment on the spot, confident that it is covered by their health insurance plan.

With AI, you can support faster care for your members and deliver faster turnaround times, helping you increase both member and provider satisfaction.

Ready to reimagine utilization management?

Your organization’s utilization management can transform the entire process into an intelligent and automated workflow that supports all of your business metrics. You can reduce medical costs and overhead expenses while also improving patient and provider satisfaction.

Olive has proven results: supporting 87% touchless reviews, an average 8 days faster patient care, and a net promoter score of 75. Are you ready to reimagine utilization management? Learn more about our payer solutions.