Prior Authorization AI Automation 

A few facts about the current State of Prior Authorization in the U.S. Healthcare market.   

• Over a quarter (27%) of prior authorizations are often or always denied by insurance companies. 
• Request and Statusing Delays: These can result in missed timeline requirements and financial losses, amounting to a 2-5% loss of topline revenue for healthcare providers.  
• A majority of doctors (62%) said prior authorization has led to additional office visits, with 64% saying authorization hassles have led to ineffective initial treatments. Nearly half of physicians (46%) said prior authorization has resulted in patients needing immediate care, including emergency department visits.
• $35 Billion is spent in the US each year on administrative costs for Prior Authorization
• There is an average of 300k changes to a Payors health plan per year.  

Recent study indicated that the use of light AI and RPA went from 10% approval to 90% approval improvement 

The CampTek Prior Authorization AI Automation solution uses a multi-pronged approach to solve the myriads of challenges presented by submitting Authorizations in an accurate, timely and successful way.  

Our solution is composed of several parts:  

1. Automation and AI First. Using AI, we can take a historical view of the 835 files from your top Payors to identify high level trends around denials by Payor, CPT code, Diagnosis, physician and patient demographics. 
   Using this data, we build Prior Authorization Automations that perform both the Request and Status parts of the workflow. Our data team begins to pull the data from the automations to feed the AI Model.  
   These automations are bespoke and will work any EMR, Payor Portal, Availity, Waystar or other clearing houses. See examples of the Prior Auth Request and Status Bots running in action.  
2. Intelligence Building. Once the automations are running in production, we begin gather data an intelligence around the authorizations that are getting statused, this data will be fed to the data model continuously. In addition, any changes in the Payors plan that are communicated via their website, pdfs or other forms are also fed to the data model to make the AI more intelligent. 
3. Intelligence Consumption. This approach, in time, will provide incredible value in that it can react and adapt to Payor changes but also ensure that the Prior Authorization submitted will be completed and have a higher chance of acceptance. The outcome will be capturing lost top line revenue and providing specific inhouse intelligence for Prior Authorization using predictive, generative and analytic AI intelligence. This can be consumed in a platform independent way (agentic AI Bots, data analytics programs, ChatBots, Epic or other applications that have API integration).   
   This is a feed and use the “brain” approach all while giving an operations team the tools it needs to be efficient, save on costs and capture the revenue that would otherwise be written off. Payors are increasingly using AI, so this is a crucial strategy for Providers to have this on their roadmap. 

Overview of the Full Prior Authorization AI Solution 

Standardized Systems & Payors works with:  

• Epic 
• Cerner (Oracle) 
• eCW 
• Siemens 
• MEDITECH
• Availity 
• Evicore 
• Magellan 
• UHC 
• Cigna 
• Any Payor with a Portal and/or API Capability 
• Any EMR/EHR both large and small.