AI-powered prior authorizations generated 4X ROI for this health system

May 26, 2021

Prior authorizations are the number one administrative burden for providers today. Let these sobering facts sink in:

  • 92% of care delays are due to prior authorization issues
  • 70% of denials are related to prior authorization or medical necessity
  • 1 hour each day is spent by physicians on prior authorizations

It’s clear we cannot accept the status quo. Prior auths are weighing down our health systems, adding administrative waste and causing physician and patient dissatisfaction.  New England Baptist Hospital (NEBH) had had enough with their current system for handling prior authorizations. They knew they needed to look somewhere new for a different solution. What they found was Olive, a solution delivering true end-to-end automation through the power of artificial intelligence. Almost immediately, NEBH experienced incredible results — reduced care delays, decreased denials, increased patient satisfaction — and generated a 4X ROI. They shared their story in a recent webinar, Transforming Prior Authorization Throughput with Artificial Intelligence and Automation. Here’s what they said:

The cost of prior authorization

NEBH is a large orthopedic specialty hospital in the Boston area, with five locations and performing 14,000 surgeries each year. It is part of the larger Beth Israel Lahey Health system. In that system, NEBH has always been one of the strongest financial performers and a leader in areas such as authorizations-related denials and write-offs. But still, NEBH was having problems with its prior authorization processes. The process of obtaining a prior authorization was time consuming, requiring manual phone calls, faxes, and portal checks. On average, it was taking 11 days from the time an order was submitted to the time the patient was scheduled. It was impacting patient throughput and leading to denials and write-offs, staff burnout, care delays, and even dissatisfied practice affiliates.  “At one point here at Baptist things had gotten so bad that a number of our private practices actually started to divert imaging orders from NEBH to a standalone imaging center in this area, and of course that resulted in a loss of revenue for our institution.” – Jon Shaker, Executive Director of Surgical Business Operations and Patient Access of New England Baptist Hospital Each of these factors impacted NEBH’s bottom line. Diverted procedures and denied claims directly impact revenue. Increased staff turnover and time spent on prior authorizations were resulting in skyrocketing administrative costs. Plus, errors or denied prior authorizations could leave valuable ORs empty at the last minute, leaving potential revenue on the table.  “When there’s a last-minute cancellation, it can be upwards of $20,000 - $25,000 for a joint replacement, and the most expensive resource in a hospital, the operating room, lies fallow.” – Jon Shaker But at the end of the day, the most important factor is that these problems with prior authorization are hurting patients. Waiting for care, in pain, rearranging their lives, and getting increasingly frustrated with their provider. New England Baptist Health wanted better for its patients. 

Why ‘best practices’ weren’t cutting it for NEBH

Recognizing the need for improvement, NEBH started down the path of industry ‘best practices.’ The hospital centralized its scheduling departments, brought in consultants to optimize workflows, invested in new software that integrated with its EMR, and even implemented a special pre-cert team to confirm all surgeries the day prior.  “Unfortunately, none of this was good enough. We may have been adhering to industry standards or best practices per se, but there was an obvious and glaring gap in what we were accomplishing and what our patients and our physicians expected of us as an organization.” – Jon Shaker NEBH needed something more, something innovative. Today’s standard of electronic prior authorization wasn’t enough. So they turned to artificial intelligence. 

Transforming prior authorizations with AI

Olive is more than a point software using basic automation or a knowledgebase of payer rules: She is an end-to-end artificial intelligence solution.  Olive’s AI technology determines if a prior authorization is needed through a bi-directional integration with the customer’s EHR and Document Management System — and then automatically confirms with payers if a prior authorization is required. She then retrieves medical necessity policies and requirements from over 40,000 health plans and helps identify and submit clinical documentation from the EHR to payers.  “We maintain direct connections with payers… including over 40,000 national, regional and state health plans.” – YiDing Yu, Executive Vice President and Chief Medical Officer of Olive Olive sees every authorization through to completion by checking payer portals for the status multiple times a day, and approval information is integrated directly back into the EHR.

The proof is in the numbers: Automated prior authorizations pay off for NEBH

Today, NEBH is live with the solution in orthopedics, physical therapy, imaging, and their pain clinic (essentially, every service at Baptist that potentially requires an authorization). The results have been dramatic:
  • 78% reduction in turnaround time from when an order is received to when a patient is scheduled
  • 35% decrease in write-offs
  • 25% reduction in staffing costs
  • 4X ROI in the first 12 months

NEBH was able to earn referral physician business back and recapture the revenue that had been diverted to the standalone imaging center. ORs are full, and schedules are running smoothly. And best of all, the hospital can remain an innovator and provide the best possible care to their community.  “I like to think of this transformation as a win, win, win situation. The physicians are satisfied with the increased efficiency and ease of interacting with the hospital now. Our patients are receiving their care in a timely fashion, and the hospital is doing better financially.” – Jon Shaker Now, after more than two years working with Olive, they have seen sustained results by streamlining prior auth operations with AI, improving their bottom line and increasing overall patient satisfaction.

Are you ready to transform your prior authorizations with AI?

Learn more about the only end-to-end automated prior authorization solution on the market.