Every healthcare provider, hospital administrator, and patient advocate is searching for better value in the healthcare dollar. It seems the industry continues to expand, being 12% of the US GDP, but opportunities to increase the razor-thin margins dwindle as oversight and regulations continue to multiply. One aspect of healthcare that continues to grow as a logistical and operational ordeal is managing the healthcare payment lifecycle and recognizing reimbursement due for the service provided.

What’s needed is a real game changer; something that advances the technology available by leaps and not just small steps. Artificial Intelligence (AI) is quite likely one answer that everyone is searching for and just beginning to understand. When directed at the reimbursement process, the implications for bottom line improvement are remarkable and implementation costs are insubstantial by comparison.

Artificial Intelligence and Patient Access

The third-party payer requirements continue to expand as the healthcare industry grapples with cost containment and necessity of care, all the while trying to maintain or even improve the patient experience. One area that gets a lot of attention during the patient access phase of the billing lifecycle is prior authorization.

A patient presents for care, a treatment plan is developed and now, depending on the insurance carrier, everything must be put on hold while the preapproval process gets underway. Even though this has long been viewed as one of the most time-dependent functions administratively, according to the Council for Affordable Quality Healthcare (CAQH), only 23% of healthcare organizations use an automated prior authorization process.

By embracing AI-assisted technology, stakeholders across the industry could see a collective annual savings of $273 million and untold improvement in patient satisfaction. Ideally, a prior approval process using an AI solution flow would include:

  • Determining if an authorization is required
  • If required, submitting an electronic prior authorization request
  • Automated follow-up with payers with real-time status updates to efficiently schedule patient care
  • Automatic system updates when authorizations arrive
  • Ongoing monitoring of visits, refills, etc., approved by insurance carriers with not-to-exceed limits
  • Highly trained specialists to proactively handle outliers
  • STAT emergency approvals in less than 30 minutes

AI and Revenue Cycle Management

Denial recovery accounts for a significant percentage of Revenue Cycle Management (RCM) efforts and can result in a 30% erosion of net patient revenues if not properly executed. What if you could accurately forecast collectible dollars, prioritize efforts, and streamline next best actions before committing any human resources? You would realize faster recovery and increase cash flows while reducing your aged accounts receivable!

Ideally, an AI-enhanced solution would automatically:

  • Evaluate claims data and create initial actionable insights
  • Prioritize the follow-up process aiming at capturing the maximum return
  • Create predictive insight algorithms for next best actions to be taken
  • Predict AR recovery potential for future planning and staffing
  • Decrease unnecessary write-offs that gouge the bottom line

By tackling aging claims problems and preventing growing denials in the future, AI brings a formidable solution to bear on an ever-present problem in the healthcare universe.

With an engaged and discerning patient population, radical improvement to the prior authorization process and active resolution of denials are two ways that AI can benefit the healthcare payment lifecycle and increase bottom-line results. Artificial Intelligence in healthcare is a solution deserving serious consideration and active implementation has an ROI unequaled by comparison.

Contact us today for a AI-enhanced prior authorization software demo.