The United States leads the world in having the largest per-capita healthcare expenditure exceeding $9,000 per person. While costs are more pronounced in the US, it’s clear other countries and regions have similar burdens. Nevertheless, despite having the largest per-person expense, US life expectancy is the lowest among other advanced economies such as Australia and Canada. Meanwhile, the cost of US healthcare in exceeds $3 trillion and approximately 30% ($1 trillion) is allocated to overall administrative costs including medical billing and related areas.
Surprisingly, a recent survey conducted by the American Medical Association (AMA) reported on average approximately 37 preauthorization insurance requests per week per physician, involving a combination of most staff members including the doctor. These efforts on average equated to approximately 16 hours per week. Recognizing that approximately 850,000 physicians are practicing within the US, these efforts translate into a sizable cost in the billions, and a factor contributing to physician burnout.
Health insurance companies use the prior authorization or pre-approval process to verify that a certain drug, procedure, or service is medically necessary before it is done (or before a prescription is filled). If the service is provided prior to preauthorization, the patient could be responsible for the full cost, with the insurer paying nothing, and the provider faced with further revenue risk.
Preauthorization is a burden to healthcare stakeholders in multiple ways:
- It creates financial risk for both patients (if they end up with a large unexpected co-pay) and providers (if they fail to recover the revenue or if there are recovery delays);
- It creates administrative costs on both the provider side (as they need to verify coverage/obtain pre-authorization) and the insurer side (as they need to manage the authorization process, often involving multiple iterations as information is missing or incorrect); and
- It impacts patient experience, as waiting for authorization delays their care.
Amelia, as an advanced cognitive and conversational AI platform, has capabilities that can deliver beneficial outcomes for all of these stakeholders, reducing costs, increasing revenue capture and improving overall patient experiences.
What Amelia Can Do
Unlike other companies attempting to deliver value to the preauthorization process by clinical support systems, automation systems, or analytics-based entities, Amelia utilizes her broad range of conversational and autonomic system management skillsets. She can simultaneously improve costs and revenue, as well as provider and patient satisfaction.
Current preauthorization-related activities are acknowledged to be fragmented, stressful, costly, and often require multiple successive calls from staff members, including the clarification of and transfer of relevant patient information residing within multiple sources. In addition, the preauthorization process requires the delivery of relevant clinical and administrative information to payer utilization management staff.
In addition, Amelia’s natural language, multi-turn and empathetic conversational capabilities allow her to engage in multilateral conversations to clarify information, request missing elements, and keep stakeholders updated on the overall process.
Amelia’s capabilities and operating environment bring scalable value to the preauthorization process. She can engage with a wide range of stakeholders and integrate with many disparate systems. She can accomplish this by leveraging her unique abilities including but not limited to:
- Manage and streamline not only custom workflows but complex integrations with enterprise systems;
- Engage with natural unscripted conversation with all staff members and where appropriate third parties, and enable users to switch between multiple requests and topics within a single conversation; and
- Generate business intelligence through her advanced analytics capabilities, including machine learning in order to provide valuable patient insights.