Digital Clinical Assistant (DCA)

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.

Prior Auth Process As-Is

Prescriber opens the EMR and prescribes the prescription.

The pharmacy will notify the prescriber that a prior auth is needed

Prescriber will submit an electronic request for prior authorization through ePA or insurance portals

Prescribers and their staff input patient demographic information and history and answer clinical questions as they come in. 

The staff is constantly checking for status updates

Duplicate requests come in, typically at night and over the weekend. If the PA request isn't completed quickly enough, these must be filtered out manually.

Backlogged workbaskets and data-entry errors cause care gaps and delays in treatment.

Increased administrative burden is the number one cause in provider burnout and a significant cause for loss in revenue

DCA Optimized Prior Auth Process

The Clinician Opens the EMR and prescribes the medication

DCA monitors the EMR and other systems for PA work and kicks off the automated process

DCA auto-triages PAs and removes ALL duplicate requests as they come in

DCA auto-fills forms via APIs and submits the requests for medications it has been configured for based on your practices' volumes

DCA creates a work queue for any encountered exceptions

nurses work only the PA requests or clinical questions that the DCA is not configured for, saving time for high-value work

Based on payer rules, the DCA posts status updates/tasks to EMR and auto-updates status

60% reduction in manual effort

50% improvement in time to approval

100% elimination of duplicate requests

See more patients, improve employee satisfaction/retention, and get home on time!