Russ Thomas, CEO at Availity, shares that 80% of the prior authorization requests made through the company’s Intelligent Utilization Management solution are “touchless,” meaning that responses are returned without the need for manual processing by staff at either the provider or the payer. Their AI-assisted processing does end-to-end authorization reviews in under 90 seconds, most in less than 20 seconds, so that the patient can learn the answer while still at the clinician’s check-out desk. This is Availity putting into action now what payers recently announced wanting to do by 2027.
He calls Availity “the largest network in healthcare,” direct connected to 95% of health plans and aiding 3-1/2 million providers.
Even so, he laments, only 33-40% of the approximately 4-1/2 trillion dollars their systems handled last year came through as reimbursements. The rest was waste—not through fraud or abuse, he hastens to say, but through mistakes and complexity in the billing systems. This is a big opportunity for healthcare they want to help improve.
He believes that his clients have a “head start” in complying with last year’s CMS rule on Interoperability and Prior Authorization. But he says that compliance with the rule will not be enough to automate workflows as Availity is doing, and is worried that some payers will get by with minimal compliance.
In contrast, he is seeking “patient delight.” He believes that Availity appeals to payers who want to differentiate themselves and address one of worst pain points clinicians complain about. Payers also find that they can direct their staff toward the few cases that need complex handling. And clinicians are delighted to get fast answers.
Among providers using Availity, reconsiderations and appeals dropped by 90% in a pilot with a health plan, because the system ensures that the needed documentation is submitted and upholds transparency. Furthermore, in contrast to the fears harbored by some payers, utilization hasn’t increased.
Their AI involves machine learning, which is more appropriate for the kinds of analysis they do than the trendy generative AI. Rather than making guesses based on large numbers of similiar cases, their model considers each payer’s medical policy and the precise conditions for each patient.
Availity’s Intelligent UM platform started with prior authorizations that are common and usually simple, including imaging, oncology, sleep treatment, behavior modification, and genetic testing. They want to extend their success to many other disciplines.
In breast cancer, which Thomas calls “super-complex,” they are working on an “end-to-end condition review program.” They hope to get prior approval for every step, even as conditions change during treatment: initial diagnosis, recommendation, treatment, and follow-up.
They also look forward to an API that can allow providers to submit a request right of the EHR.
Watch the video for more details about Availity’s service, the role of culture, and the CMS rule.
Learn more about Availity: https://www.availity.com/
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