The following is a guest article by Kayt Leonard, Global Health Care Strategic Advisor at SAS
The healthcare industry in the United States is no stranger to regulatory changes. As we reach the mid-point of 2024 and look towards 2025, it’s not a secret that the healthcare landscape is set to undergo significant transformations – both from a regulatory and legislative perspective.
In the middle of these changes, organizations still have one mission: to serve their patients, members, and healthcare consumers with the best experience and outcomes possible. So how do they do that, while balancing the shifting regulatory landscape?
One answer: technology.
With the buzz of artificial intelligence (AI) and tools like generative AI, along with the historical promises of machine learning, and advanced analytics, the technology needed to ensure continuity of care – and continuity of experiences – already exists for both healthcare payers and providers. However, in many cases, the technology either hasn’t been implemented or hasn’t been used to its maximum potential.
So, where do organizations start? There are 4 areas in which technology can empower payers and providers to effectively drive positive change, all while preparing for potential changes in healthcare regulations:
Streamlining Medical Record Review
One of the challenges that payers and providers face is the need for efficient medical record review processes. With impending regulatory changes, the demand for accurate and timely reviews will only increase. Technology can play a pivotal role in automating this process, leveraging AI, computer vision, and machine learning to capture key insights and data points from medical forms and other unstructured data. This not only reduces administrative burden but also enhances accuracy and speeds up the review process, allowing healthcare organizations to make informed decisions promptly.
Simplifying Prior Authorization
Prior authorization is often a complex and time-consuming process for both payers and providers. However, advanced analytics can streamline this process by digitizing workflows and enabling electronic submission and approval of prior authorization requests. Advanced software tools can integrate with electronic health records to automate the verification of medical necessity criteria, reducing manual errors and improving efficiency. This ensures that patients receive timely access to necessary treatments, while payers can maintain appropriate utilization control, oversight, and documentation.
Enhancing Member and Patient Engagement
Regulatory changes often require increased transparency and engagement with members and patients. Technology can facilitate effective member and patient communication, enabling healthcare organizations to share information about plan changes, coverage options, and cost-saving opportunities. Through secure patient portals and mobile applications, individuals can access their health data, track claims, and engage in telehealth services. Moreover, advanced analytics can help providers identify gaps in care, generate personalized health recommendations, and improve patient outcomes.
Leveraging Data for Improved Decision-Making
The availability of vast amounts of healthcare data presents an opportunity for payers and providers to make data-driven decisions. With the help of technology and emerging analytic leadership, organizations can harness the power of data analytics to identify trends, predict patient or member needs, and optimize resource allocation. This enables proactive care management, targeted interventions, and cost-effective strategies. Additionally, analytics-based technology platforms can assist payers in projecting outcomes based on real-world evidence, aiding in the development of value-based payment models and driving improved quality of care.
As the US healthcare system braces for more regulatory changes in 2024 and 2025, technology becomes a crucial ally for both payers and providers. And, staying ahead of the regulatory curve with innovative technology solutions will empower healthcare organizations to adapt, thrive, and deliver high-quality care in an ever-changing environment.
Whether it’s streamlining medical record review, simplifying prior authorization, enhancing member and patient engagement, or leveraging data for informed decision-making, AI-driven technology solutions hold the key to successful navigation through these changes.
About Kayt Leonard
Kayt Leonard is a Global Health Care Strategic Advisor at SAS. Prior to joining SAS, Leonard worked across the industry with payers, providers, physicians, and pharmaceutical organizations. Leonard’s research in health equity, disparities, and global healthcare access has been recognized by the World Health Organization, the Centers for Disease Control, the Food and Drug Administration, and the European Medicines Agency.
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