Atlantic Well being streamlines insurance coverage authorization with clever automation
When the COVID-19 pandemic began, Atlantic Well being System, like different healthcare suppliers, discovered itself below monumental stress. Along with coping with sufferers struggling the results of a brand new virus, healthcare suppliers needed to deal with new care protocols, staffing points, and provides shortages spurred by the pandemic, all of which positioned extra stress on any current friction in healthcare administration processes.
“The pandemic and the getting older inhabitants and rising inhabitants actually put very excessive stress on each healthcare system, and Atlantic Well being was no exception,” says Sunil Dadlani, chief info and digital officer and chief cybersecurity officer on the New Jersey-based nonprofit healthcare community. “You mix that with workforce shortages, provide chain shortages, and plenty of different issues which are happening.”
Atlantic Well being serves a inhabitants of 6.2 million folks, with greater than 400 websites of care, together with six hospitals, and because the group struggled with these points, it rapidly grew to become obvious that insurance coverage authorization for imaging and radiology companies — a foundational diagnostic step earlier than virtually any care can start — was a bottleneck. When care is time-sensitive, any delays can have an effect on affected person outcomes.
Scheduling and receiving authorization for healthcare companies has historically been a extremely complicated and guide course of. Every of the greater than 100 radiology practices throughout Atlantic Well being System was chargeable for its personal authorization requests, which required important funding of time and a spotlight to administrative duties.
“Our sufferers come from completely different backgrounds, and so they have completely different payors. Every payor has its personal codecs, its personal necessities, its personal processes,” Dadlani says. “With the rising quantity of radiology, it created a way of urgency, as a result of we have been seeing the next variety of denials in pre-authorization. We noticed the next quantity of extra documentation that was wanted for pre-authorization.”
To deal with these challenges, Atlantic Well being System undertook a undertaking it referred to as Prior Authorization Clever Automation, which has earned it a CIO 100 Award in IT Excellence.
Dadlani and his IT group collaborated with Atlantic Well being System’s radiology and affected person entry service traces to streamline the processes concerned in acquiring prior insurance coverage authorizations by means of use of automation. The undertaking group used clever rule-based evaluation to determine companies that require authorization and prioritize submitting them to payor portals. The automation polls the payor portals for updates and retrieves authorization info with out the necessity for a human within the interplay.
By expediting the method, essential procedures could be scheduled earlier than the prior authorization course of begins, which means sufferers now not have to attend to obtain crucial follow-up care.
After all, with so many practices, clinicians, and group members concerned within the prior authorization course of, succeeding in clever automation was no imply feat. At the beginning, it required standardizing the prior authorization workflows distinctive to its greater than 100 radiology practices. The follow operations, physicians, and know-how groups needed to develop a brand new prior authorization request course of, which included the creation of a brand new centralized pre-services group to supervise prior authorizations for the complete group.
Establishing a brand new pre-services group enabled the person practices to dump the executive burden of acquiring prior authorization, and simplified the method of coaching the person practices on the clever automation resolution. The undertaking group, collaborating with the brand new pre-services group, used a sequence of webinars and small group classes to assist every group perceive their new tasks and generate buy-in.
For Dadlani, the important thing to success was beginning with a concentrate on the enterprise drawback, not know-how.
“We began by partnering with the best stakeholders in order that we may truly outline the best drawback,” he explains. “As an alternative of beginning with the automation, we began with the enterprise course of.”
For the IT group, that is important as a result of applied sciences and know-how distributors come and go. Dadlani notes that his group is at all times excited about three issues: vendor refresh, know-how refresh, and skillset refresh.
“We now have realized over time that there are at all times disruptions taking place in our companion’s ecosystems,” Dadlani says. “So we’re continually evaluating the enterprise relationships we construct over time to ensure we’re finest positioned for the years to return.”
Prior Authorization Clever Automation has helped Atlantic Well being System scale back the period of time it takes to submit authorizations by greater than 50%, which can be 50% under the trade common. As well as, 70% of all authorizations throughout the radiology service line are actually dealt with by means of clever automation and fewer than 1% of appointments are canceled on account of denied or delayed authorizations.
“By way of course of, we have been taking days,” Dadlani says. “We’re at lower than 4 minutes.”
Dadlani is now searching for methods to increase the group’s success in automating prior authorization for radiology companies to Atlantic Well being System’s different service traces, like surgical procedure and cardiology.
“We aren’t performed,” he says. “We picked up imaging. Now we need to prolong this to different areas. We now have a confirmed use case, confirmed leads to scaling this out on the enterprise degree for radiology.”
Dadlani recommends that know-how leaders looking for to implement clever automation of their organizations hold an open thoughts and be prepared to fail good, be taught quick, and adapt.
“Do you might have a tradition of collaboration and communication? That’s crucial,” he says. “You will need to perceive the issues or the challenges your companions are having. Your mindset ought to be to make them profitable and remedy these issues.”
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