How AI is Cutting Prior Auth Denials & Reducing Peer-to-Peer Reviews
July 24, 2020
Prior authorization denials are an infuriating headache for practices, especially when they result in a peer-to-peer review—placing an administrative stranglehold on clinical operations & busy surgeons. Providers spend hours gathering documentation for submission only to have the prior authorization denied by the payer.
When the only thing that is standing between a patient and an essential procedure or scan is prior authorization, something needs to change. According to the AMA, 91% of physicians report that prior authorization has led to care delays, with 78% reporting abandoned tests or procedures altogether. Patients already wait days to weeks for their prior authorization and are forced to wait even longer when payers deny prior auths.
Often, payers deny prior authorizations because more information is needed. With hundreds of health plans and unique payer rules, it is easy to submit the wrong documentation or miss something altogether. Denials can be appealed and overturned with peer-to-peer reviews, but appeals take extra time and sometimes a great deal of extra effort—further postponing essential patient care.
That’s where artificial intelligence can help. Employing AI technology to identify payer rules for prior authorizations, ensures the correct documents are submitted the first time around—limiting denials and time-consuming peer-to-peer reviews with generalist medical directors employed by payers.
Case Study: Prioritizing Prior Authorization to Reduce Prior Auth Denials & Peer Reviews
For one practice, stringent payer requirements and peer-to-peer calls diverted staff attention away from patient care to time-consuming prior authorizations. Staff spent hours on the phone with payers and sorted through stacks of paperwork to find the correct documents. Practice affiliates and surgeons grew frustrated with delays and the high rate of denials—to the point of diverting imaging orders to standalone practices resulting in lost revenue. Patients grew frustrated with their providers, not understanding why the process was taking so long.
This practice turned to Verata to start prioritizing prior authorizations. Reducing denials and peer-to-peers, as well as increasing provider productivity and removing barriers to patient care, were their primary concerns to address. With Verata’s prior authorization AI, this practice saw improvements almost immediately. 75% of staff saw fewer denials that required peer-to-peer reviews, freeing up valuable time for staff members to focus on their patients. Most importantly, patients benefited, too. 100% of staff reported that turnaround times were faster, giving patients better access to care and much-needed peace of mind, instead of waiting in limbo for days to weeks.
Employing artificial intelligence to overtake administrative busywork is transforming practices in a matter of weeks. By using automation to match thousands of unique payer rules to the correct clinical documentation, denials and peer-to-peers reviews have dramatically reduced. Patients no longer wait days or even weeks for their critical procedures, and providers are free from the administrative stranglehold of prior authorization denials.
To learn more about Verata Health, and how we are helping practices reduce denials and peer-to-peer reviews, contact us today.