Automating prior authorization in real time: from EHR to utilization management

Prior authorization is the largest administrative burden on providers, which often results in tense relationships with contracted payers. An individual ordering physician spends an average of 16 hours per week, or $80,000 each year. Payers aren’t immune to this administrative burden either. In 2019, the average cost for a prior authorization was $3.321. More importantly, according to the American Medical Association’s annual physician survey, 91% of physicians said prior authorization can lead to negative clinical outcomes for the patient2.

Edifecs is fully automating prior authorization at the point of care by utilizing the provider’s EHR system. Rather than go to a separate portal, providers can now request prior authorizations right in the electronic health record. We’re enabling electronic forms and automating this process by leveraging AI technology and existing EHR integration from our Risk Adjustment business through our Talix and Health Fidelity acquisitions. Our solution also utilizes FHIR® Standards to ensure ongoing compliance while improving collaboration between the payer and provider, enhancing patient outcomes, and improving satisfaction.

Sources:

  1. 2019 CAQH Core Index
  2. 2021 Prior Authorization Annual Physician Survey
Infographic - Prior Authorization

Products

Utilization Management

Prior authorization approvals can take up to 30 days, resulting in suboptimal care and experience, not to mention, delays of claims payments. Deliver prior authorization RFAI, decision timing, and status of the EHR seamlessly.

  • Processes unstructured data for submission
  • Full human workflow for prior authorization case management and peer reviews
  • Generation of internal reports (aging, alerts, performance) to external federal and state agencies reports
  • Assistance with audit, appeals, and follow-up processes
  • Integration with existing utilization management systems

Deploy Artificial Intelligence (AI) and Machine Learning (ML) to aid in utilization management decision support.

Policy Management

Clinical guidelines are hard to consume and change frequently, creating substantially inefficient and potentially error-ridden processes for providers who have to guess or use trial and error. Facilitating the intake and storage of clinical guidelines within the EHR enables better efficiency and accuracy.

  • Intake & storage of clinical guidelines
  • Connects directly to clinical guideline repository
  • Compliance with federal & state legislations
  • Vendor agnostic clinical guidelines intake
  • Management of electronic guidelines exposure for line of business, benefits, networks, and more

Integrate prior authorization requirements into the EHR as automated forms.

Clinical Integration

In today’s world, communication between providers and payers is inconvenient and difficult to document at the point of care. This results in disrupted care for the patient when providers have to leave the exam room to call or fax the plan. Establishing a real-time communications channel enables seamless collaboration between the care team and payer.

  • EHR-agnostic multi-payer support through Smart on FHIR®
  • AI/NLP for data extraction
  • Automate prior authorization forms based on payer medical necessity guidelines
  • Support for FHIR® interfaces

Establish a secure, fully electronic, integrated, real-time communications channel in the EHR.