, are betting big on generative AI solutions to improve efficiency and reduce the time and cost burden of manual PA processing for providers and payers.its partnership with Microsoft to accelerate generative AI-powered 'copilot' tools to help clinicians save time on PA requests.
Nellis touts the company’s novel approach, in which it ingests prior authorization rules from partnered health plans and applies those rules within a provider’s EHR workflow, as a key reason the company has seen its technology deployed to more than 1,000 hospitals.Health plans, for their part, are also embracing AI capabilities to improve PA processing.
As with all things shiny and new in healthcare, especially when introducing automation to care decision-making, the industry must proceed with caution. Take the class action brought against health insurer Cigna in July, which alleges Cigna’s PA screening algorithm was developed “to systematically, wrongfully, and automatically deny” its members of a physician’s review of PA requests as “guaranteed to them by California law.”, is whether the technology in use is in compliance with the state and federal insurance regulations that govern payer decision-making on whether to approve claims or prior-authorization requests.
Perhaps the most important takeaway is automation and efficiency can’t come at the expense of someone’s health, and AI solutions are by no means a silver bullet for PA transformation.Neither information exchange nor AI will fix what ails today’s PA problem. Technical standards will help, but are not sufficient, as they leave a “many to many” inefficiency problem requiring every EHR system to connect and maintain integrations with every health plan system, and vice versa.