Since 2019, we have been supporting prior authorization processing for a national imaging network’s in-house patient access team. Our tech-enabled solution, Patient Access Plus, was brought on to help them with:
- Determining prior authorization requirements efficiently,
- Initiating cases with precision through the appropriate benefit manager,
- Ensuring timely follow-up and successful completion of cases.
Our Authorization Determination Agent AI
Patient Access Plus leverages AI and automation to streamline prior authorization workflows for our clients.
One key feature using AI is our Authorization Determination Agent (ADA) AI, which determines if authorization is required or not. It is designed to intelligently analyze and learn from millions of historical prior authorization cases processed by our solution, harnessing data across a vast array of payers, procedures, and geographical diversities.
With over a decade of experience in processing prior authorizations nationwide, our robust proprietary data set is our strength. This vast wealth of information empowers our clients when they opt for our solutions.
Most of our clients use ADA to determine whether authorization is required or not. To ensure ADA is performing with accuracy, a sample of AI-determined “No Auth Required” cases is always manually audited for performance tracking and feedback learning. Claims data outcomes for these determinations are also used.
Our Experiment: ADA AI vs Manual Processing
For this specific imaging network client, our prior authorization specialists were processing authorization determinations. As case volumes surged, we proposed an experimental application of ADA to convince them to rely on it. They agreed to the experiment.
We transitioned from manual to automated authorization determinations using ADA for select cases, aiming to demonstrate its superior efficacy and accuracy. During the trial, we restricted ADA’s application to high-confidence “No Auth Required” cases. While ADA ran in parallel, our specialists continued with manual determinations, allowing us to accumulate ADA’s decisions without influencing the ongoing process.
Our objective was to benchmark ADA’s AI-driven accuracy against the specialists’ decisions and corresponding claims outcomes, the latter being the gold standard for validation.
ADA Accurately Determines Whether Prior Authorization Is Required With 98.5% In Real Time
After a meticulous three-month comparison, ADA’s accuracy was validated at an impressive 98.5%, with detailed accuracy metrics by payer:
- UHC, 98.7%
- BCMS AZ, 98.2%
- Aetna, 95%
- Humana, 100%
- Arizona Foundation for Medical Care, 95%
Transformative Benefits of ADA AI Implementation
Our client’s satisfaction led to the full-scale implementation of ADA. The advantages are multifaceted, including:
- Accelerated scheduling and enhanced patient volume due to rapid turnaround
- Resource optimization with staff redirected to high-value tasks like patient care
- Elimination of time-consuming follow-ups with payers
- Reduced staffing pressures and recruitment needs
If you are looking to achieve similar results at your organization with the prior authorization solution, contact us at www.infinx.com/request-a-demo.
Missing prior authorizations are a top cause of claim denials. How accurate is your team in determining whether a prior authorization is required? Read how one national imaging network with dozens of locations improved its denials rate by activating the AI-powered authorization determination agent (ADA) feature of our prior authorization solution.