Prior Authorization Automation for Top Medical Supplier

Client Profile

Founded in 1994, our client is a leading provider of home healthcare supplies and services, supporting more than 200,000 patients living with chronic conditions throughout the U.S. Working with more than 400 employers and more than 1,800 managed care plans, the private equity-backed company is focused on ensuring patients have access to the supplies and support they need to manage their conditions effectively.

The U.S. health sector has historically struggled to put innovations including automation into practice, due to fears of switch-over disruptions, lack of expertise, and concerns about initial and hidden costs of adoption.

However, sticking with manual, paper-based processes can cause critical errors, delays in providing care, and can put the compliance of healthcare service providers at risk, while also leading to wastage of time and resources for employees.

Amid rising healthcare costs, the potential for cost savings from automation is immense: wider adoption of AI can lead to savings of 5-10% in U.S. healthcare spending – roughly $200 billion to $360 billion annually, according to a 2023 paper published by the National Bureau of Economic Research.

Recognizing these benefits, the medical equipment supplier approached Auxis, a leader in Robotic Process Automation (RPA) and AI-led automation, to conduct a review of its business processes and identify automation opportunities. The Auxis team performed operational assessments of different departments throughout the organization, working with the client’s department heads and process owners.

More than 20 processes were reviewed in the following areas – revenue cycle management, operations, finance, and HR – identifying challenges, pain points, business benefits, and automation potential. Together, Auxis and the client identified prior authorization status checks as the first and most critical process ripe for automation.

A whopping 99% of durable medical equipment requires prior authorization from insurance payers – and 60% of healthcare finance leaders rank prior authorization among their most time-draining tasks, according to a 2023 RevCycleIntelligience report.

For the client, key challenges included:

• Single-use products require frequent re-authorization. Along with durable purchases like insulin pumps, the client sells a large quantity of single-use consumables such as needles and hoses that must be constantly replenished. With insurance prior authorizations only valid for a limited time, the client had to continuously re-execute the process to fulfill orders. As a result, there was always a huge volume of pre-authorization requests that required processing.
• Prior authorization status updates come without warning. Before it can fulfill a customer order, the medical equipment supplier needs to submit supporting documentation and request prior authorization in the insurance payer’s web portal. Payer response time typically varies between two and seven business days, and comes without warning or notification of status change.
• Overwhelming, tedious workloads distract staff from more important work. Till now, only two inefficient solutions were available for healthcare enterprises with highly manual processes and high prior authorization volumes, like the Auxis client. They could hire large teams to log into payer portals and waste time checking for decisions every day until they appear. Or they could delay checking order statuses for about two weeks – letting enough time lapse that they felt confident an approval, partial approval, or denial would have been sent to the portal.
• Delays registering a payer’s approval or denial stretch the order cycle. Given the large volume of pre-authorizations the client’s team had to follow up on, staff were only able to check each order’s status once every three days – often causing days to pass before a payer response was registered. Unfortunately, that caused the client to lose out on the opportunity to deliver products as soon as they were approved or appeal denials immediately, increasing delivery cycle times and decreasing speed to revenue.

The medical equipment supplier recognized that streamlining its cumbersome prior authorization process was key to delivering the best customer experience, increasing speed to revenue, and optimizing use of staff’s time.

Auxis leveraged market-leading RPA platform UiPath to optimize the medical supplier’s prior authorization status checks. RPA is a proven solution for transforming revenue cycle management (RCM) functions fraught with time-consuming steps and frustration – offering healthcare organizations the ability to orchestrate and automate workflows involving a variety of legacy and new prior authorization software systems, implement best practices, analyze prior authorization metrics, and restructure inefficient processes.

The Council for Affordable Quality Healthcare Index recently asserted that fully automating nine common revenue cycle management transactions can save the U.S. healthcare system $16.3 billion. Manual prior authorization processes cost healthcare providers about $700 million annually, according to CAQH research.

Auxis came to the table with the tools, best practices, and expertise the client needed to automate its process for checking the status of prior authorization requests effectively. Its Intelligent Automation team combines more than 25 years of business process optimization experience with an elite status as a UiPath Platinum Partner, the automation platform’s highest partnership level.

Auxis’ RPA team also brought deep experience building prior authorization automation that navigates the complexities of extracting information from the web portals of some of the largest payers for multiple healthcare clients.

RPA represents the best solution for connecting to payer portals since application programming interfaces (APIs) with this capability are not currently available. The Auxis team utilized UiPath’s User Interface (UI) automation capabilities to build bots that can seamlessly log into the portals and search the prior authorization status of each order.

Auxis deployed four RPA bots to automate prior authorization status checks for the five largest insurance payers the client works with – alleviating the biggest burden for staff. Key steps from Auxis’ automated prior authorization solution included:

• Logging into payer portals.
• Checking the status of prior authorization submissions daily until the payer responds.
• Extracting prior authorization decisions for each order.
• Updating patient records in the client’s system with approval, partial approval, or denial status.

Auxis’ expertise with automated prior authorization solutions enabled it to build bots capable of connecting with the payers’ portals within an incredibly fast, three-week timeline. After thorough testing and staff training, Auxis’ automated prior authorization solution was up and running smoothly within five weeks.

Ensuring compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations was another critical objective. Auxis developers built robust controls to secure data and safeguard patient privacy for the client.

Auxis’ RPA-led prior authorization automation solution accelerated the most time-consuming step of the revenue cycle management process for the client: prior authorization status checks for the five largest payers.

Key benefits include:

67% increase in prior authorization status checks minimize order delays

With verification frequency increasing from once every three days to daily checks, changes to order statuses are captured and updated on the same day they are received – minimizing order delays.

Zero human intervention required to check status for five largest payers

The Auxis bot alleviated a significant burden for the medical equipment supplier’s staff, successfully checking and updating the status of 2,600 prior authorization requests per month across the client’s five largest payers.

Faster speed to revenue

Reducing the time between order and delivery expedites order fulfillment and billing, increasing speed to revenue for the client.

Competitive advantage

Faster delivery cycles create a valuable differentiator in a market serving patients who rely on access to these products to alleviate chronic conditions, which helps boost physician referrals and repeat orders.

Reduced human error

Bots execute tasks according to defined and programmed rules and therefore do not make errors that humans are prone to make. This greater accuracy came as a huge relief to a large back office responsible for a high volume of tasks, avoiding errors that can cause order delays.

Employees shifted to more proactive, high-level problem-solving

Having automation take over low-value tasks freed up the medical supplier’s human staff to focus on more nuanced orders requiring detailed review. Typically, turnover also decreases after an automation initiative due to the reduction in tedious, manual work and stress caused by overwhelming workloads.

Easy scalability

Auxis’ automated prior authorization status check solution design is reusable, meaning additional payer portals can be added with simple adjustments to meet future demand.

New automation opportunities offer potential for significant savings

Based on the overall organizational assessment Auxis performed, the Intelligent Automation team delivered an automation roadmap to help the client unlock future benefits across the enterprise, identifying and prioritizing more than a dozen opportunities. The company has committed to implementing a slew of automations which could approach $1 million in cost savings, including:

Automated extraction of claims denials from payer portals, denial reason review, and upload of details to the client’s core systems.

Other key challenges that automation can address include validating orders that are ready to ship, flagging orders with pending or missing documentation, gathering supporting documentation for prior authorization submissions from physicians, and more.

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