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January 16, 2024

Generative AI for Healthcare: Helper or Hindrance in Automated Prior Authorizations?

by Susan Lawson-Dawson | Healthcare Technology, Prior Authorization

It only took ChatGPT five days to surpass 1 million users. Two months later, the generative AI application boasted an impressive 100 million active monthly users, and that figure keeps climbing. Is it any wonder that the healthcare industry has been buzzing about the potential of generative AI?  Where is the potential greatest?  An August 2023 AMA Survey found that physicians are most enthusiastic about leveraging AI tools to reduce administrative burdens, such as automating prior authorizations. That fits with expert assessments as well. Forbes reported last fall that, “According to a McKinsey analysis, AI-enabled prior authorizations can automate up to 75% of manual tasks. This potential is why many tech companies, including giants like Google, Microsoft, and IBM, are betting big on generative AI solutions to improve efficiency and reduce the time and cost burden of manual PA processing for providers and payers.” 

Addressing concerns crucial to leveraging generative AI successfully

Of course, like any technology, generative AI has potential downsides. Already, we’ve seen cautionary tales of generative AI’s potential for hallucinations,  bias, or data privacy and security concerns. However, used in the right way, generative AI can help reduce the administrative burdens that providers face—a fact that has not gone unnoticed by physicians. 

In the August AMA Survey, for example, 69% of physicians acknowledged generative AI’s relevance for improving workflow efficiency.  As AMA Trustee Alexander Ding, M.D., M.S., M.B.A., notes in a June 2023 press release, “AI holds the promise of transforming medicine. We don’t want to be chasing technology. Rather, as scientists, we want to use our expertise to structure guidelines and guardrails to prevent unintended consequences, such as baking in bias and widening disparities, dissemination of incorrect medical advice, or spread of misinformation or disinformation.” 

With the understanding that generative AI is not a panacea, healthcare providers, payers, and health technology organizations  must approach its integration with a blend of caution and strategic foresight.  

  • Establish regular and rigorous auditing to mitigate the risk of biases baked into training data and help ensure fairness and accuracy. 
  • Implement robust security measures to protect sensitive patient data, as well as other proprietary information.
  • Ensure that human judgment remains part of the process, using generative AI as a complement, not replacement, for the nuanced decision-making of medical professionals.

Risk mitigation is critical in this context. From vetting of AI decisions to continual education of healthcare teams on the effective and ethical use of AI tools, a measured approach helps ensure generative AI delivers measurable value.  

Physicians definitely want to be kept in the loop. Citing the AMA Survey, Modern Healthcare notes that “Eighty-six percent of physicians reported a desire to be either responsible for or consulted before their practices adopt tools that use AI.”  By taking a comprehensive, transparent approach, organizations are better positioned to leverage generative AI as a beneficial tool in healthcare, augmenting human expertise while safeguarding against its potential downsides.

How generative AI supports automated prior authorizations

Let’s face it: prior authorizations are bureaucratic beasts. The traditional approach involves a significant amount of paperwork, back-and-forth communication between providers and payers, and, consequently, delays in patient care that negatively impact health outcomes.

By harnessing the power of large language models (LLMs) and machine learning, generative AI can sift through vast amounts of data and interpret insurance policies and guidelines. 

  • Converting Chaos to Clarity:  By converting disparate information into well-organized formats, generative AI empowers a streamlined prior authorization process
  • Enabling Automation of Manual Processes: Those tedious tasks that eat up hours of your day? AI’s on it, automating the process so clinicians and staff can focus on patients, not paperwork.
  • Consistency Is King: With AI-enhanced automation, human error gets a reality check. Fewer typos or missing information establishes more uniformity in the quality of prior authorization submissions, facilitating faster processing of requests.
  • Decision Intelligence at Your Fingertips: On the payer side, data-driven clinical decision support makes it easier to approve requests that meet the same criteria.

Taken as a whole, AI systems trained on vast datasets can identify patterns and nuances that people can easily miss. Ultimately, it elevates the quality of patient care.

Generative AI holds great promise for enhancing healthcare processes like prior authorizations, but its integration requires a careful approach. By acknowledging the potential challenges and taking proactive steps to address them, healthcare providers and payers can utilize AI as a powerful ally in the quest for better patient outcomes and more efficient administrative processes. 

The future of healthcare is not solely human or artificial. It represents a collaborative venture that, with the right guidance, can lead to an era of unprecedented efficiency and patient-centered care. Want to see what AI-empowered prior authorizations look like? Connect with Myndshft to get started.