Tapping into health insurance can be tricky. Many times, your health care provider can refer you to a physical therapist and your insurance will cover it without hesitation. And there are instances where your doctor has to get approval from your insurance company BEFORE you can access physical therapy to ensure it qualifies for payment coverage.
This requirement is called prior authorization. And it’s typically needed for referrals to see a specialist, certain medical treatments, procedures and tests like CT scans. At OSF HealthCare, a team with the Revenue Cycle department ensures this process runs smoothly behind the scenes.
“In the past, our Mission Partners were tasked with manually going to an insurance company’s website daily for updates on approvals or denials to prior authorization or referral submissions,” said Jacque Doerman, a patient access director with the Revenue Cycle. “We wanted to figure out how to work smarter, remain fiscally responsible and do away with repetitive tasks that can become mundane.”
As a result, the Revenue Cycle division sought Advanced Analytics’ help to automate this process, allowing Mission Partners to spend more time on difficult cases that need human intervention. Using robotic process automation technology, Advanced Analytics created a bot that works alongside Mission Partners to check on pending authorizations.
How the bot works
The software bot created for prior authorization automation is the first one developed by Advanced Analytics, a part of OSF Innovation, to run on top of the electronic medical record (EMR).
Advanced Analytics worked with Compliance, Auditing, Privacy and Security to test the bot and build standardized processes around gaining approval to use the automations within the EMR. The Analytics Effectiveness team helped move the project forward by coordinating the collaboration between various groups and making sure roadblocks were addressed quickly.
“It was fun to build something that’s never been done within OSF before,” said Joe Gannuscio, manager of the automation services with Advanced Analytics. “Our strong partnership with Patient Access and Compliance led to the creation of a robust solution that is safe from a patient perspective and efficient from an automation perspective.”
The bot scans the electronic medical record (EMR) and gathers prior authorization and referral requests that haven’t been approved. It logs into the appropriate payer portal websites and enters the information needed to get the status of those submissions. The bot then logs into the EMR and updates whether those requests have been approved, denied or are still pending.
“The bot then notifies Mission Partners when a case is ready for a human to take over,” said Gannuscio. “Otherwise, they can just let the bot continue to check the status of a prior authorization or referral that could be pending for days or weeks.”
This frees up time for Mission Partners to personally reach out to insurance companies that don’t have portals with prior authorization statuses or require a more complex process to complete an authorization. Mission Partners can also spend more time working on denials that may require additional documentation or follow-up to ensure an authorization is secured prior to service.
“Sometimes we need to submit more clinical paperwork and answer more questions,” Doerman said. “We may also need to have a provider talk with the insurance company to justify why something should be authorized.”
As of now, the automation system does more than 90 different checks a day and runs seven days a week.
“The prior authorization bot has allowed us to work further out and reduce the workload and stress our Mission Partners had,” said Doerman. “It’s also helped us ensure we are not canceling services at the last minute for patients because we are getting prior authorizations ahead of time.”
Advanced Analytics has taken what it’s learned from building the prior authorization bot and bundled it for others on the team to use for future processes.
Advanced Analytics is in the process of developing a bot to check whether a prior authorization is required or not. That will soon move into testing and could go live by the end of the year. The team is also working on building a digital assistant to help with submitting prior authorization requests.
All of this work is part of an OSF HealthCare expansion of Advanced Analytics to include Automation Services and serve additional portions of the Ministry. Automation Services works to build human-machine partnerships where bots and people can work seamlessly together. The goal is to make better use of Mission Partner time, expand capacity to support strategic priorities and improve patient experiences in key processes.
Last Updated: February 11, 2022