Availity Blog

How AI, Automation, and Data Interoperability will Revolutionize the Future of Prior Authorizations


8.09.2023 By Availity


How AI, Automation, and Data Interoperability will Revolutionize the Future of Prior Authorizations

Prior authorizations are a critical utilization management tool in healthcare. However, they rely heavily on manual interventions and analog technologies—making them burdensome and potentially impeding timely patient care. In fact, according to the American Medical Association’s 2022 Prior Authorization Physician Survey, 94% of respondents reported care delays, 80% said that issues related to the prior authorization process could lead to patients abandoning a recommended course of treatment, and about a third reported a serious adverse event due to prior authorizations. Yet, the underlying cause of frustration is not the prior authorization but the manual processes supporting it.


The adoption of electronic prior authorizations remains the lowest among all healthcare transactions, despite the potential savings of around $450 million annually. This is because prior authorizations are not purely administrative or clinical but instead a conversation that addresses both. Key tactical details on the administrative side, including patient information and procedure or test orders, must be integrated with subjective aspects on the clinical side, such as prior treatments, comorbidities, and specific plan coverage.


Bringing Clarity to Prior Auths

To improve the prior authorization process, healthcare industry stakeholders must acknowledge its complexity and create a framework that brings administrative and clinical information together, making wider adoption of electronic transactions possible and effective. Standardizing the administrative components of authorizations, encouraging interoperability, and integrating AI into the end-to-end process are critical focus areas that will help the industry achieve this.


True integration among provider and payer systems is possible with standardization and interoperability, and technology vendors from both payers and providers are necessary to facilitate the exchange of clinical and administrative data into a more seamless process. With access to required data, prior authorization workflows can be automated, reducing the administrative burden on staff. The key will be applying automation to protocols already well-aligned across payers to enable faster processing for patients within a standard protocol.


For example, one of the earliest abrasion points between payers and providers occurs at the onset of the authorization process—determining if a prior authorization is needed. Payers can reduce many authorization-related calls by ensuring providers have essential information early in the process and providing a central location for submission and management, including determining if an authorization or medical attachment is required and whether a delegated vendor manages the authorization.


Another factor complicating prior authorizations is the requirement to include medical documentation for clinical review. Reliance on fax and mail to exchange records increases the chance that information will be lost, leading to a delayed response from the payer. As a result, digital correspondence provides an opportunity to streamline the process. Rather than relying on fax machines, phone calls, and other analog solutions, health plans, and providers can leverage an intuitive, API-connected interface to exchange digital correspondence, including authorization determination, clinical documentation requests, and other authorization-related tasks.


Responsible AI

Prior authorization is also an ideal use case for AI to tackle, specifically in answering the question of medical necessity. We can train AI to understand the health plan's medical policies and evaluate each unique case on the merits of the clinical information submitted. This approach is a radical departure from other approaches to automate approval decisions using regression models, which inherently introduce bias into the system and offer no transparency or auditability of the decision.

The potential impact is significant as authorizations are approved in about 85% of cases today. If that 85% can be automated, human intelligence can focus on the 15% of cases that need a more thorough review.


Availity, as the nation's largest real-time health information network, believes that widespread adoption of electronic standards and attendant automation capabilities will lead to a significant reduction in administrative burdens, reduce the cost of care, and improve outcomes for patients. Our products and services are designed to acquire, enrich, and exchange clinical, administrative, and financial health data in ways that are automated, compliant with national standards, consistent with its original intent, and refined for broad-scale application and actionable intelligence.


Availity processes more than 13 billion electronic transactions a year across thousands of payers and millions of providers. Additionally, Availity has served as an active collaborator with industry organizations, including Health Level Seven International (HL7) DaVinci Project, the Workgroup for Electronic Data Interchange (WEDI), ASC X12, and the Cooperative Exchange to advance standards in data usability and exchange. Our suite of solutions creates a comprehensive, end-to-end authorization platform that streamlines the critical functions of the authorization process and empowers providers and payers to manage prior authorizations more effectively.


For more information, download our End-to-End Authorizations white paper.



Share a link

play video