Wipro Prior Authorization Automation Powered by AI

Prior

authorization or prior approval is a health plan cost-control process by which

physicians and other health care providers are required to obtain advance

approval from a health plan before a specific service is delivered to the

patient to qualify for payment coverage. It is

one of the most common and time-consuming tasks in the healthcare revenue cycle

process and most of the health plan denials and underpayments are attributable to

prior authorizations. It

is therefore important to get timely approvals at the point of the physician's

order or referral. It provides a better opportunity to ensure the receiving

provider gets appropriately paid and the patient gets prompt service.

A recent survey from the American Medical Association

(AMA) found that 88% of physicians reported that prior authorization

generated high or extremely high burden, with physicians completing an average

of 41 prior authorizations each week, the survey also revealed that prior

authorizations frequently delayed access to necessary care for patients or led

patients to abandon their treatment altogether due to the waiting period or

other prior authorization issues.

About the Solution:

The

solution built on Microsoft technologies is a workflow based prior

authorization automation process with automated clinical appropriateness

checking. Through artificial intelligence-powered clinical reviews, the tool

can determine if the health plan will cover the needed services almost

immediately.

Key

features:

The

solution features multifaceted strategies including rewarding providers who

have a high percentage of approvals and reducing manual burdens involved in the

prior authorization process and introducing proactive authorizations to help

decrease time to decision such as:

• Recognize

clinicians who are regularly approved for prior authorization by lifting the

requirements for a limited time

• Eliminate

prior authorization for drugs, medical services and equipment that are

regularly approved

• Use AI-ML

models to analysis the prior authorization request and provide recommendation

for a timely decision

• Patients

with pre-diagnosed medical conditions can be preapproved for treatments and therapies

that are typically requested for their conditions

• Clinical

Decision Support and real-time pharmacy benefit checks can be used to inform

clinicians for a timely decision and increase quality of care as well.Benefits:

The solution provides various benefits to the Health

plans, Patients and Providers such as

Health Plan

• Speeds up decision making (from days to hours)
• Improves patient and clinician experience (NPS scores)
• Improves the member engagement and care co-ordination

Member/Patient

• Reduces the delay in medical treatment

services and medication

• Significant reduction in

healthcare spending

• Avoid onset of chronic conditions

and disease progression

Provider

• Reduce

delay in providing patient care

• Reduce

administrative burdens and focus on patient care

• Focus

on at-risk individuals and populations.

For more details about this Healthcare Cloud focused offer, please click on 'contact me' button.