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Myndshft Blog

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September 21, 2023

Transformative Tech: Unlocking the Potential of Intelligent Prior Authorization

by Susan Lawson-Dawson | Healthcare Technology, News, Prior Authorization

You can’t talk about transforming healthcare in the US without talking about prior authorization. There. We said it. Of course, we aren’t alone. Politicians, providers, payers and patients all recognize problems with prior authorization. It’s not surprising, then, that intelligent prior authorization earned a spot on the Gartner Hype Cycle for Healthcare Payers in 2023. How does intelligent prior authorization differ from the status quo?  Currently,  the typical prior authorization process is manual or a clunky combination of manual and electronic steps that acts as a bottleneck in patients’ care journeys. By using natural language processing, artificial intelligence, and HL7 FHIR APIs, intelligent prior authorization helps organizations escape this administrative maze.

What makes intelligent prior authorization a smart choice? 

Intelligent prior authorization frees staff and clinicians from tedious, time-consuming data entry. After entering minimal data, automation takes over, pulling in relevant information from disparate sources. By streamlining a previously unwieldy process, intelligent prior authorization reduces friction between providers and payers and smoothing the care pathway for patients. What’s more, payers can leverage capabilities like clinical decision support and data-informed auto-adjudication to accelerate decisions. In turn, this decreases the risk of patients’ conditions worsening due to care delays. Think of the litany of prior auth woes it will solve. 

For Patients

  • Efficient processing of prior authorizations improves the speed to therapy—which can be critical especially for time-sensitive treatments—ensuring better health outcomes.  
  • Faster access to medications also decreases prescription abandonment and increases medication adherence. 
  • By minimizing denials and errors, patients face fewer out-of-pocket costs from resubmissions and can better manage their medication budgets and adherence.

For Providers

  • The productivity boost aids with ongoing hiring shortfalls because staff and clinicians can transition to higher-value, patient-focused tasks. This relieves some of the pressure contributing to burn-out. Plus, better staff experiences help reduce turnover. 
  • Greater efficiency and accuracy lowers operational costs associated with submission, status tracking, and reworking preventable denials. 
  • Improving the speed and quality of prior authorization submissions helps keep the revenue cycle running smoothly. And that productivity boost pays off here as well because less time spent on paperwork means more capacity to help more patients. 

For Pharmacies

  • With automated prior authorization software, pharmacies can ensure patients get their medications faster, translating to improved customer satisfaction and loyalty.
  • Automated systems decrease the chance of errors common in manual prior authorization processes, leading to fewer claim denials, quicker approvals, and improved profit margins.
  • Reducing manual intervention in the prior authorization process helps pharmacists and pharmacy staff concentrate on patient counseling and medication therapy management, elevating the role of pharmacists as essential healthcare providers.

For Drug Manufacturers

  • Faster and more accurate prior authorizations increase the speed at which new medications reach patients, resulting in quicker market penetration and better return on investment for new drug launches.
  • Automated systems provide valuable data analytics, offering insights into approval rates, patient demographics, and prescribing trends, enabling better marketing and distribution strategies.
  • By simplifying the approval process, manufacturers can enhance relationships with healthcare providers, positioning their medications as not only clinically superior but also easier to prescribe and dispense.

For Payers

  • Built-in clinical decision support offers an unbiased, consistent approach to prior authorization approvals. By delivering uniform decisions based on clinical evidence, intelligent prior authorization reduces errors and boosts trust among healthcare providers and patients alike.
  • Data-informed auto-adjudication likewise streamlines the approval process. Because intelligent prior authorization captures approval and denial data, the system can recommend approvals based on past performance, identifying requests that meet the same standards previously approved for batch processing. 
  • With health equity top of mind among healthcare stakeholders, intelligent prior authorization ensures that approvals are based on objective clinical criteria rather than subjective judgment. By removing the arbitrariness often associated with manual reviews, intelligent prior authorization levels the playing field for all patients.

Why is momentum for adopting intelligent prior authorization on the rise? 

New state and federal mandates are poised to address different problems associated with or posed by prior authorization. For instance, the Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule CMS-0057-P currently being finalized by the Centers for Medicare & Medicaid Services (CMS) will place new requirements on “impacted payers” to facilitate better data exchange and streamline prior authorization processes.  

  • Medicare Advantage (MA) organizations
  • State Medicaid and CHIP Fee-for-Service (FFS) programs
  • Medicaid managed care plans 
  • Children’s Health Insurance Program (CHIP) managed care entities
  • Qualified Health Plan (QHP) issuers on Federally Facilitated Exchanges (FFEs)

While the “impacted payers” list does not currently extend to private payers and employer-sponsored plans, regulations are not the only source of pressure. Gartner attributes growing pressure for payers to solve the prior auth problem to increased media scrutiny, noting that it is “… elevating reputational risk as a primary business decision driver—potentially eclipsing actuarial math.”  You don’t need to look far for proof. When one payer announced it was going to begin requiring prior authorization for colonoscopies and 60 other endoscopy codes earlier this year, the subsequent viral backlash resulted in a reputational firestorm and the payer revising its initial decision.  

No wonder Gartner puts intelligent prior authorization in the “Transformational” benefit bucket. 

We’re proud to say that Gartner mentioned Myndshft as a sample vendor pioneering the advancement of intelligent prior authorizations. Mainstream adoption is expected within the next 5 to 10 years, but we’re ready to help now. Together, let’s transform healthcare for the better.

Reach out to Myndshft to get started.