by Heather Kawamoto, Chief Product Officer, Recondo Technology

June 2019 – Healthcare has a high turnover problem, and not just for clinical staff. In many hospitals, especially in rural areas, it is notoriously difficult to find employees with specialized expertise in working with healthcare insurance companies on various revenue cycle transactions.

Compounding the problem is that these high skilled professionals are often put to work on repetitive tasks that make little use of their best skillsets. Instead, they spend hours on the phone with payers to check on the status of claims that either have been or will be approved, or repeatedly logging onto payer websites to verify a seemingly endless queue of authorization requests.

Such tedious work soon burns out staff that should never have been tasked with doing it in the first place. It also costs the healthcare organization—and our overall national healthcare bill—dearly. Some years back it was estimated that insurance-related billing and administration costs accounted for nearly half a trillion dollars in the United States each year. For individual hospitals, communicating with payers requires a large staff of full-time employees; a need that grows only greater when these hospitals merge with or are acquired by another.

Consider the steps involved in requesting a single authorization for a procedure or test. If doing so online, it typically takes at least 15 minutes to visit a payer’s website to make the query, copy and paste data into numerous fields, and submit the request. Conducting these transactions over the phone is even slower, as most healthcare insurance companies will only process three requests at a time. As it isn’t unusual for one hospital to have 20,000 or more prior authorizations to request every month, we can see the true scope of the challenge in having enough staff on hand to process all of these transactions.

No surprise, then, that hospitals are responding by automating these transactions instead. But far more than simply replacing manual, human effort with AI-powered technologies such as robotic process automation and natural language processing, these efforts include a concept called “exceptions-based workflow” that routes more complex transactions to the appropriate staff to manage them.

Here’s how—again, using the example of a prior authorization request. With robotic process automation, web bots log in to a payer’s website using the provider’s credentials. Once logged in, the bots input various data fields—such as patient’s name, service or procedure being requested, and some other rote data. In a new advance, natural language processing can be enabled at this point to input the data for actual clinical questions. Once the entire request is fulfilled, it is submitted. As soon as the payer answers, this information is then relayed back to the provider.

Depending on the answer, it either goes straight to the hospital information system, or to the work queue of a specialized staff member for additional attention. Obviously, a denied prior authorization will be sent to the latter, who has expertise in understanding why a prior authorization might not have been granted and can begin to prep what’s needed to resubmit the request.

There are other examples. Many hospitals are using AI now to automate the similar process of checking on the “Approved” or “Denied” status of claims, or to generate accurate estimates of a patient’s cost of services. Automation can also streamline the task of verifying if a patient is even eligible for services, a transaction that, when paired with automated prior authorization, can drastically reduce the rate and volume of denied claims. This is particularly beneficial now that more hospitals routinely take on the responsibility of obtaining prior authorizations from payers on behalf of non-employed providers with hospital privileges.

Ultimately, all of these newly automated transactions speed up payment of claims, which otherwise can take up to 40 days or longer. They also avoid the need to pursue costly fixes such as staffing up internally or hiring expensive third party call centers to follow up with payers on missing claims.

What they don’t do is make human effort obsolete. Yes, far fewer staff hours are needed to perform repetitive phone calls and website log-ins. But most hospitals are responding by redirecting specialized staff to work the transactions that need their expertise the most. Thanks to intelligent use of automation, these  professionals are finally working at the top of their licensure.

About the Author

Heather Kawamoto is Chief Product Officer at Recondo Technology. With over 20 years product management experience, Heather’s products have received coveted industry awards and rigorous certifications. Her broad experience both with organization size and responsibility scope (product management, marketing, inside sales, sales support and client services) contribute to her success helping healthcare organizations realize cost savings and operational efficiencies through automation-focused technologies. A well-respected thought leader, Heather’s commentary has been featured in healthcare media outlets such as Modern Healthcare, HealthcareNOWRadio, and Becker’s Hospital Review. Heather is also a frequent panelist at industry conferences hosted by HFMA, NAHAM, Becker’s and others.


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