Leveraging AI to benefit the healthcare ecosystem for providers, payers and members

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The findings below were part of a 2022 McKinsey & Company study on the effects of applying artificial intelligence (AI) to the prior authorization (PA) process. The research revealed that leveraging AI will strategically benefit the entire healthcare ecosystem for providers, payers and members.

"Our analysis suggests that artificial-intelligence-enabled prior authorizations can automate 50 to 75 percent of manual tasks, boosting efficiency, reducing costs and freeing clinicians at both payers and providers to focus on complex cases and actual care delivery and coordination," the study revealed.

To understand why McKinsey's researchers were able to make such a bold claim, let's review how most health payers receive PA requests today. A 2021 AMA survey found that nearly half (47%) of providers always or nearly always submit PAs for medical services via paper-based fax machines.

That means a big chunk of the PA requests your staff has to process is received as unstructured data on fax machines. Digital fax pages are technically "images," as well, not data. That means your staff needs to manually review these faxes, prioritize the cases and often manually re-enter the information into a database.

Prior authorizations and the inefficiencies of unstructured data

A 2020 study by the CAQH found that manually reviewing and responding to PA requests -- communicating with providers by phone, mail or paper fax -- costs payers an average of $3.14 per transaction. The researchers also estimated that payers could reduce this average cost to just pennies per transaction -- while also ensuring timely delivery of care -- by automating and digitizing at least part of the process.

Why? Because the burdens of reviewing and processing unstructured data in PAs submitted as faxes via paper or cloud creates enormous challenges for payer organizations. Here are just a few examples:

• Payers can't automatically sort and prioritize traditional faxes according to member need or urgency.
• Manually reviewing and acting on fax-based PAs takes staff longer and results in slower responses to all PA requests.
• Manual data re-entry of unstructured fax content increases the chance of human mistakes, which can lead to substandard health outcomes and an increase in the total cost of member care.

Here's another way to think about it: Let's say you received 100 names in an Excel file, and you needed to rearrange them into alphabetical order. That task would require only a few clicks because the software can easily distinguish the letters in the names and has the built-in intelligence to order them from A to Z.

Conversely, let's say you received those 100 names on paper. Resorting them alphabetically won't be as easy as clicking a few buttons; someone will need to manually rewrite every name on the list or type them into a database.

This is a very high-level analogy, but it underscores the difference between an AI-enabled PA process and the name-on-paper process that your organization is likely challenged with every day.

Here's how you can overcome these obstacles for both your members and your bottom line.

Remove manual processes with digital cloud faxing

Even if providers continue to submit PAs using legacy fax systems, your team doesn't necessarily need to receive those requests as hardcopy documents.

The right digital cloud fax solution -- one customized to fit your unique needs as well as the constraints of the healthcare industry -- can ingest inbound fax content into electronic health records (EHRs) or other records systems. It can also leverage basic optical character recognition (OCR) to identify key data in your faxes, such as member names, ID numbers, names of physicians, etc.

This straightforward addition to your organization's digital environment can remove several time-consuming, inefficient manual steps from the review process to help your staff streamline their PA responses and, ultimately, save your organization money.

Sort and organize key information using natural language processing (NLP)

When it comes to automating the management of PAs, NLP takes digital cloud faxing a step forward. Otherwise, any inbound fax content would need to be manually reviewed and processed by your staff.

NLP embedded in your cloud fax platform can automatically sort and organize the key information in an inbound fax, and even take a next step if necessary. For example, you can instruct your NLP solution to scan every inbound fax for key terms -- "urgent," for example -- and prioritize those requests by sending alerts to the right people in your organization.

As NLP employs machine learning, it will continually grow more adept at identifying key terms and concepts as it consumes more data. It can even learn to read handwritten notes on fax pages.

Employ AI for increased efficiency

Your organization will see the greatest operational benefits when you employ AI for your PA processes. AI brings together all of the capabilities listed above while adding layers of learning, thinking and continuous improvement to your fax solution.

Returning to the McKinsey study cited earlier, the research team concluded that "an AI-enabled workflow requires fewer steps," automating most of the administrative tasks most payers currently handle manually. AI can also benefit payers by sorting requests according to priority, as well as sorting those that can be handled by RNs from those that need a doctor's input.

Bottom line: Because fax (both paper and digital) remains one of the most common methods for providers to submit prior authorization requests, payers must employ new tools and technologies to receive, review and process these requests as efficiently and reliably as possible.

The best and easiest way to do this today is to implement the right digital cloud fax solution with built-in AI and NLP capabilities. Doing so will lessen the burden on payers' staff, streamline their ability to respond to PAs, reduce overall costs to the company and improve both member and provider outcomes.

By Bevey Miner, HIT Strategist, Consensus Cloud Solutions