The Challenge

• Prior authorization is the most burdensome process for many providers
• The number of procedures, drugs & DME requiring prior authorization continues to grow
• Payers, providers, and CMS do not utilize common prior-authorization rules, standards, documentation, or processes –this causes up to 80% of initial prior authorization denials
• Manual prior authorization processes are getting costlier due to additional administrative burdens.
• Many delays in patient care are directly related to prior authorization delays and data entry errors, resulting in risk to the patient and questions from them and their families.

The Solution

• Centralized prior authorization work-bench with optimized workflows, case tracking, and reporting
• Automated retrieval of the most up-to-date formularies and prior auth guidance by payers
• Automated gathering of disparate data and documents for consolidation and initial fulfillment of prior authorization requests
• Real-time, intelligent notifications and tasking for prior authorization team to ensure efficient exception processing
• Built-in assistance for prior authorization nurses through the centralized workbench
• Exception-only involvement of prior authorization team, guiding to improve the initial prior authorization submittal process in the future.

The Benefits

• Reduce prior authorization costs by up to 60%
• Reduce the decision time on prior authorizations by up to 50%
• Provide hundreds of hours per year back to nurses to provide quality care, as opposed to prior authorization administrative tasks
• Increase the rate of first-pass approval of prior authorizations by up to 50%
• Decrease patient’s likelihood of abandoning care due to frustration or inconvenience
• Retain the familiarity of your EMR for physicians while streamlining the process for nurses
• The DCA requires no changes to your existing EMR system

No modifications to the workflow are necessary for pediatrics

FQHCs, Primary Care, Mult-Specialty Physician Groups, Hospital Clinics, Physician Groups, Medical Group Practices, Independent Medical Practices, Telehealth providers, Ambulatory Surgery Centers, Urgent Care Centers, Hospitals, Pediatricians, Dermatologists, Endocrinologists, Gastroenterologists, Cardiologists, OBGYN, Community Health Centers, Rural Hospitals, Non-Profit Hospitals, Specialty Group Practices.

Industries: Healthcare, RCM

Provider Systems: Epic

Payer Portals: eviCore, United Healthcare, Magellan

Challenge

A large healthcare provider needed to ramp up their automation strategy to offset labor instability and attrition. Currently the staff manually have to go out to payer portals, submit requests and check statuses of Prior Authorizations, sometimes multiple times. Through Task Mining AI (Artificial Intelligence) analysis, it was determined that staff were spending about 30 – 40% of their time submitting requests and checking the status for 19,000 prior authorizations per month.

Prior Authorization Requests: 3 bots processing prior authorization requests in 3 separate portals (EviCore, Magellan and UHC).

• EviCore: 923 transactions per month
• Magellan: 595 transactions per month
• UHC: 7,063 transactions per month

Prior Authorization Statusing: 3 bots processing prior authorization statuses in 3 separate portals (EviCore, Magellan and UHC).

• EviCore: 5,536 transactions per month
• Magellan: 3,572 transactions per month
• UHC: 986 transactions per month

Solution:

RPA bots are a much more accurate and effective solution to verify the status of patient health authorizations, RPA bots can repeatedly check requests under review for status changes and updates.

CampTek Software was engaged because of its healthcare and Epic experience. Through task mining, AI models were created, and results were reported back to the customer with enormous success. The next phase of design and build all occurred in a brief time. The bot now in production includes business rules, exception handling and daily reporting functionality. It is also supported by CampTek as an ongoing managed service solution for the provider.

The Bot is now saving 2,696 FTE (full-time employees) hours per month or 32,352 hours (about 3 and a half years) per year. The FTE capacity gain is 17 FTEs (full-time employees), and the ROI (Return on Investment) is $1,085,000 per year.

Any healthcare provider