The first U.S. payer to deliver automated point-of-care prior authorizations

June 4, 2021

Can the current prior authorization process be truly transformed? That’s the question a large nationally recognized payer asked themselves as they evaluated their current system and considered possibilities for innovation. The answer they found was yes, with the power of artificial intelligence. During the Modern Healthcare Transformation Summit, Tina Cummings, VP of Clinical Operations and Performance, was joined by Dr. Jeremy Friese, President of Payer Market at Olive, and Dr. YiDing Yu, Chief Medical Officer and Executive Vice President at Olive, to share their story of prior authorization transformation and automation using artificial intelligence. If you missed it, here’s the recap: Or watch the full webinar here.

The prior authorization problem

Prior authorizations are still being completed through phone calls and fax machines, eating up hours of valuable payer and provider time as payers struggle to get complete, accurate patient information to ensure appropriate utilization management. At the end of the day, it’s a drain on healthcare resources, adding to the costly administrative overhead and resulting in frustrating care delays. There are plenty of solutions on the market, as this nationally recognized payer found, but they wanted something different — something truly innovative. This organization has been in the market for 75 years and are constantly looking for ways to grow their footprint and provide exceptional value to providers and members. As they started looking at prior authorization solutions, what they found were solutions that solved small pieces of the puzzle, but nothing that was trying to take a bold, new approach to prior authorizations. As Tina illustrated, “It’s a problem you can’t ignore anymore. It’s like you solve all the way around it, but nobody wanted to go through it.” There are questionnaires and decision trees, there are electronic prior authorizations, but these “solutions” have been around for years and haven’t solved the problems. In fact, it’s been the opposite — the prior authorization burden on provider organizations has only continued to grow.

Could artificial intelligence be the prior authorization solution they were looking for?

When Tina Cummings and her team found Olive, they found a technology partner with the same goal of solving the prior authorization problem in a way that hadn’t been done before. It became a true partnership as the teams worked together to create a system that was painless for providers and members while preserving the integrity of the payer process. There were three unique, major criteria they aligned on as they created the solution:

  1. Connect directly to provider EMRs so that the solution is seamless for providers
  2. Integrate into her organization’s care management platform so that the solution is seamless for clinical reviewers
  3. Be an all-payer solution

What did these mean to providers? First, by being directly connected to provider EMRs, the system provided direct, automated access to clinical information to ensure medical necessity criteria were met. It was not a separate program or workflow for clinicians to use. As soon as a clinician writes an order, AI jumps in to automatically initiate the authorization request. AI then pulls through the clinical documents to check for medical necessity criteria. If there is a gap, it guides the user to the issue. For example, if a clinician orders a knee surgery, but AI doesn’t see any documentation for physical therapy, it will prompt the user to the gap so they can address it with the patient before submitting the prior authorization. Second, the solution needed to be seamless for the payer as well. All prior authorization requests through Olive’s platform plugged straight into their existing care management platform, supporting the transactions they were already using; 278s, 275s, 270s, 271s, anything that’s a standard transaction. Lastly, by being an all-payer solution, this organization is being a true partner with their providers. Through diligent customer research, they uncovered that a one-payer solution would be a real pain point for providers. Tina explained what they heard as, “Don’t build me a solution that’s just for this particular payer, because I do business with 8, 9, 10 different payers in the state of Florida, and... I’m not going to change my practice just for you.” So instead of creating a system that is just for one organization, adding to healthcare’s problems of siloed technologies, they decided to throw out the rulebook and deploy a platform that would be a real solution for providers and members by working for all payer portals and payer rules. Tina felt that, “As an all-payer solution, any provider with Olive can use AI to automate prior authorization submissions on their end. However, when it’s [one of our patients], AI works the process end-to-end, actually enabling point-of-care authorizations.”

Becoming the first U.S. payer to provide point-of-care authorizations

With artificial intelligence on both sides of the prior authorization process, this well-known payer and Olive have a system that can provide actual point-of-care prior authorizations for patients. As Dr. Yu explained, “That means for that member... they can leave that doctor’s visit having talked about their surgery, talked about the plan, and knowing that their insurance is going to pay for it. No more going home, waiting for that phone call, maybe two weeks. Just [go ahead] and schedule it.” Point-of-care authorizations makes this payer, on average, a week faster than any other payer. The net promoter score, a measure of user satisfaction and likelihood to recommend, on the project is 75 — on par with Starbucks and Amazon — which is simply unheard of for the health insurance industry.

Are you ready to automate your prior authorizations?

live is the first and only truly end-to-end prior authorization solution on the market, with the ability to connect payers and providers in a way never done before. Olive is already used in thousands of hospitals across the country to automate operational processes using AI, and now we, as an industry, have the opportunity to finally solve the prior authorization problem by connecting the payer market to the providers. It’s time to learn more about how AI can enable point-of-care authorizations for you and your providers.