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 technology to streamline the prior authorization process. 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, processes are inefficient for providers and payers. The root cause of this frustration is the primarily manual processes and analog technologies. These outdated methods make prior authorizations one of the most burdensome transactions in healthcare—leading to negative patient impact. That’s why 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 status and the associated rules enable us to perform an intelligent AI matching task. This task aims to determine whether the specific patient aligns with the criteria previously selected by the payer/plan.

Q: How does Intelligent Utilization Management help with prior authorizations?

A: Our applications are designed to streamline prior authorizations, making it easier and faster for all parties involved. We understand that not everyone involved in the process is a clinician. This is why we have developed a system that reads a medical record and matches it to specific payer requirements. We can reduce manual work for the administrator tasked with obtaining prior authorizations.

We also simplify the complex language in prior authorization rules that a payer typically uses, making it easier for administrative staff to understand and analyze. We’ve tried to codify those rules into everyday language with the help of 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.

Intelligent UM is designed specifically for healthcare. We understand the difficulty and manual effort involved in the prior authorization process, and the level of complexity in decision-making. Mistakes can have dire consequences in healthcare, highly accurate and reliable 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. We have taken precautions to develop a system that combines the power of AI with the expertise of human clinicians.

To help ensure the best possible outcomes; clinicians review all AI recommendations. And, the system is not a black box; recommendations are auditable and transparent. To be clear, AI never makes definitive decisions on whether a prior authorization request should be approved or denied. 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 with human in the loop workflows.

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.

To learn more about Intelligent Utilization Management, or to schedule a meeting with our team, click here!