HCSC AI-enabled pre-authentication tool reduces claim submission time to 6 minutes

The Health Care Service Corporation says its pre-authorization tool, first developed in 2021, could streamline the submission process and provide auto-approval if certain key criteria are met.

why it matters

The last auth tool was piloted in 2022 on specialty pharmacy and behavioral health requests. This year, the tool is also used for inpatient acute care, long-term acute care, inpatient rehabilitation, skilled nursing care, outpatient and inpatient hospice care, home health. and outpatient services.

Approvals once took 14 days, and are now “instantaneous,” according to a statement from the customer-owned health insurance company.

HSCS also said that its new artificial intelligence implementation is used by 93% of HSSC members for some process codes. The algorithm references historical authorities and claims to have approved treatments.

Of note, the company says the devices can’t decline pre-authorization requests — they’re approved or advanced for hands-on review by HCSC physicians and staff.

The company said the HCSC, which has 18 million members in Illinois, Montana, New Mexico, Oklahoma and Texas, has eliminated prior authorization requirements for about 1,000 procedure codes since 2018.

big trend

John Gaines, vice president of marketing at Coheer Health, recently discussed machine learning as a way to provide better pathways for pre-authorizations at HIMSS23 in Chicago.

The company applies ML to reduce the administrative burden of nurses, but also to gather rich data about members and the population.

Rather than acting as a transaction that results in a yes or no to a request, the company is using the request interaction as an opportunity to learn more about the patient and offer proactive suggestions – or evidence-based services Granting approvals that the provider has not yet requested. ,

Employees who spend an “inordinate amount of time” dealing with so many intricacies of multiple schemes can “heave a sigh of relief”, he said.

On the record

“We believe providers and payers need to work together to help make the health care process easy to use and effective to benefit our members,” said Dr. Monica Berner, HCSC Chief Clinical Officer. Is.”

“For us, ‘fixing’ prior authorization so that it works better for everyone is not a new idea, and we are happy to see others in the industry moving in that direction as well.”