Home Health Health Care Service Corp. using AI for prior authorization

Health Care Service Corp. using AI for prior authorization

by News7

Health Care Service Corp. is expanding a pilot integration of artificial intelligence into its prior authorization process, which the parent of Blue Cross & Blue Shield of Illinois promises will make the approval process for many procedures quicker and easier for providers and patients alike.

HCSC said in a statement this morning that it has been using AI technology for 93% of its more than 18 million members, for a limited number of procedure codes. The company, with Blues plans in Illinois, Montana, New Mexico, Oklahoma and Texas, is using proprietary AI in a prior-authorization tool that “streamlines the submission process and provides auto-approvals when critical criteria are met,” the statement said.

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The tool does not deny requests, HCSC said in the statement. It either approves prior authorization or kicks the request up to a human for a hands-on review by an HCSC clinician.

During an initial pilot in specialty pharmacy and behavioral health in 2022, HCSC said in the statement, approvals were granted 80% of the time for behavioral health decisions and 66% for specialty pharmacy decisions.

Earlier this year, the use of the tool was expanded to include inpatient acute care, long-term acute care, inpatient rehabilitation, skilled nursing care, outpatient and inpatient hospice care, home health and outpatient services for prior authorization.

“We recognized a few years ago the need to make it quicker and easier for providers and members to get the answers they need and took advantage of emerging technology to develop a suite of tools that simply work better for everyone involved,” HCSC Chief Clinical Officer Dr. Monica Berner said in the statement.

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HCSC received more than 1.5 million prior authorization requests in 2022.

“By triaging and approving requests that require minimal information, the technology frees up clinical staff for review of more complex requests,” the statement said.

The use of prior authorization by health insurers has been vilified by providers, most notably the American Medical Association, as often being used to simply cut costs and deny needed care.

HCSC said in the statement that it also regularly audits the procedures that require prior authorization, eliminating prior authorization requirements for nearly 1,000 procedure codes since 2018.

In Illinois, HCSC has invited select health care facilities to participate in a “Gold Card” program in which inpatient prior authorizations are auto-approved if received within three days or less of a procedure, the statement said. The program, begun in January 2022, requires facilities to meet criteria that identify their adherence to evidence-based national criteria standards of care, the statement said.

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In a white paper by McKinsey, the consultancy firm suggests that the technology can streamline health insurance prior authorization and claims processing. With prior authorizations taking on average 10 days to verify, the paper states, the task is time-intensive and costly.

“Health care payers recognize that prior authorization (PA) is ripe for improvement. AI-enabled PA design may deliver substantial financial, user-experience, and care benefits,” the paper, authored by partners in McKinsey’s Chicago, New Jersey and Melbourne offices, said.

“While the health care industry has made strides toward standardizing and automating PA,” the paper says, “the process continues to be an administrative challenge. Payers’ clinical staff must devote considerable time to reviewing PA requests. Meanwhile, doctors and staff report spending 13 hours per week on PA; many clinicians believe it undermines their clinical judgment and can inhibit timely care.”

McKinsey estimates that AI-enabled PA can automate 50% to 75% 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.

This story first appeared in Crain’s Chicago Business.

Source : Modern Healthcare

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