Problem

The manual prior authorization process was fraught with inefficiencies, causing delays in treatment, administrative burden for healthcare providers, and frustration for patients.
This negatively impacted the provider's cash flow and overall patient experience.

Solution

Implementation of an automated prior authorization workflow leveraging RPA and API integration:

• Robotic Process Automation (RPA): Bots automate data entry, retrieval, and communication tasks within the existing systems.
• API Integration: Secure connections with payer systems to real-time eligibility checks and status updates.
• Rules-Based Engine: Automation of authorization requests based on insurer-specific requirements.

Results

• Significantly faster turnaround times for prior authorizations, allowing for more timely patient care.
• Reduced denial rates due to improved accuracy and adherence to guidelines.
• Improved cash flow for the provider due to faster decision-making by payers.
• Enhanced patient experience with reduced delays and increased transparency.

Technology Stack

• RPA Platform: UiPath, Blue Prism, Automation Anywhere, or similar.
• API Integration: Securely connecting with payer systems through standard protocols.
• Rules-based Engine: Configurable logic to streamline authorization workflows.

Software Development

• Workflow Analysis: Mapping existing authorization processes and pinpointing automation opportunities.
• RPA Development: Configuring bots to interact with forms, websites, and internal systems.
• Dashboard Creation: Providing visibility into authorization status, exceptions, and key metrics.

Before Metrics

Average authorization turnaround time: 5 days
Denial rate due to missing/incorrect authorization: 8%

After Metrics

Average authorization turnaround time: 2 days
Denial rate due to missing/incorrect authorization: 2%