The Future of Healthcare: AI in Prior Authorizations

In part two of our three-part Q&A series with Robert Laumeyer, CTO, Technology Advisor at Availity, we explore the world of artificial intelligence (AI) in prior authorizations within the healthcare sector. As an experienced entrepreneur and software inventor, Robert is passionate about using cutting-edge technology to streamline the prior authorization process, making it more efficient and effective. Missed part one? Check it out here.

Q: What is the specific role of AI in prior authorizations?

A: Although prior authorizations are critical to ensure that patients receive necessary care, current processes are burdened with frustration and inefficiency for healthcare providers and payers alike. The root cause of this frustration is the primarily manual processes and analog technologies supporting it, which currently make prior authorizations one of the most time-consuming and burdensome transactions in healthcare—ultimately leading to potentially negative impacts on patient care. That’s why it is a perfect area to address with cutting-edge AI technology; it can potentially play a transformative role by automating and streamlining prior authorizations. 

 AI has the capability to extract pertinent and relevant information from clinical records for the prior authorization process. Preceding this task, a similar process involves reading and integrating the complete set of Medical Necessity Rules into a unified internal language referred to as “RML,” an abbreviation for Real Medical Language. This standardized representation of the patient’s current status and the associated rules enables us to perform an intelligent AI matching task. This task aims to determine whether the specific patient, at the given time, aligns with the criteria previously selected by the payer/plan.

Q: How does Availity AuthAI help with prior authorizations?

A: Our applications are designed to streamline prior authorizations, making it easier and faster for all parties involved. To begin with, we understand that not everyone involved in the process is a clinician, which is why we have developed a system that reads the medical record and matches it to the specific requirements of the payer. We can take much of the manual work away from the administrative person who is often tasked with obtaining prior authorizations.

We also simplify the complex language in prior authorization rules that a payer typically uses (which essentially reads as half legal and half medical), making it easier for administrative staff (and actually anyone) to understand and analyze. We’ve tried to codify those rules into everyday English language, specifically with the help of both doctors and lawyers to guide the process. This helps to eliminate confusion and ensures that everyone involved in the process is aligned. Our ultimate goal is to make the authorization process faster and easier.

It’s also very important to note that Availity AuthAI is designed specifically for healthcare, as we uniquely understand the difficulty and manual effort involved in the prior authorization process. Most industries don’t require this level of complexity in decision-making. In healthcare, where mistakes can have dire consequences, the high accuracy and reliability of AI is essential.

Q: Can you explain how your system handles decision-making and why involving humans in that process is important?

A: Our goal is to make the prior authorization process as simple and hassle-free as possible, with emphasis on accuracy and safety in all decisions made. We have taken extra precautions to develop a system that combines the power of AI with the expertise of human clinicians. It is not a black box; instead, it is transparent and traceable.

For instance, in healthcare, it’s crucial to have human validation of decisions to ensure the best possible outcomes. We have implemented a rigorous validation process, which involves having a clinician review and validate all decisions made by the Availity AuthAI solution.

Furthermore, Availity AuthAI doesn’t make definitive decisions on whether a prior authorization request should be approved or denied. Instead, the tool only offers a recommendation or provides a response of “we don’t know” if more information is required. Availity is committed to the highest ethical standards and aims to make accurate recommendations, avoid bad outcomes, and provide opportunities for all results to be reviewed.

Q: How does AI in prior authorizations help ensure the efficient processing of healthcare services, particularly for patients with critical needs?

A: AI significantly speeds up the prior authorization process, allowing patients to receive necessary care faster. For example, getting treatment promptly can alleviate stress for patients and their loved ones in cases like cancer diagnoses. In diagnostic radiology, AI can expedite scheduling, benefiting both patients and healthcare providers.

In conclusion, AI in prior authorizations is a promising area in healthcare that aims to make the process more efficient and accessible while involving human oversight to ensure the best possible outcomes. Availity AuthAI represents a significant step towards addressing the inefficiencies in healthcare and harnessing the power of AI to ultimately improve patient care.

Learn more about Availity AuthAI