Using AI and UM Workflows to Automate Prior Authorization, Determinations & More

Prior authorization can cause serious issues for members and providers if processes are not properly architected by a healthcare payor.

More than nine in 10 physicians (94%) reported care delays while waiting for health care insurers to authorize necessary care, a physician survey by the American Medical Association found. Eighty percent said prior authorization can lead to treatment abandonment, and 33% reported prior authorization issues have led to serious adverse events including hospitalization, disability, or even death.

These pain points are felt by healthcare payors too. Inefficient or inaccurate prior authorization can lead to costly mistakes, tense provider relationships that create declines in quality, and unhappy, unhealthy members.

However, there are not that many standards in place for prior authorization, though in the last few years, significant efforts have been made to improve prior authorization processes. It’s why prior authorization is a critical focus for healthcare plans and payors right now.

Why Healthcare Payors are Focused on Automating Prior Authorization

Prior authorization can be costly, inefficient, detrimental, and opaque when not properly handled by healthcare payors. It’s why the last few years the Centers for Medicare & Medicaid Services (CMS) have been working to improve prior authorization requirements.

It’s why the recent CMS-0057-F ruling set forth new requirements around prior authorization decision timelines, APIs, including reasoning for denying prior authorization requests, and metrics. (Learn more about CMS-0057-F rules here.)

And payors must be compliant with many of these new prior authorization requirements by 2026. Consequently, many payors are looking for ways to automate prior authorization including utilization management (UM) workflows for prior authorization, and AI-empowered technologies. Good thing HELIOS offers healthcare payors both configurable UM workflows that are clinically integrated, and AI-powered decisioning and automated prior authorization capabilities.

Let’s look at both items below.

AI-Powered Automations for Prior Authorization, Determinations and Review

The HELIOS platform has an integrated solution for utilization management, HELIOSum, that drives faster authorizations, streamlines, and automates UM processes, and offers automated prior authorization capabilities by leveraging AI and intelligent workflows together.

Here’s how AI is utilized in HELIOS to improve UM cycles and turnaround times:

  1. Automate prior authorization processes: Leveraging AI technologies to accelerate communication between payors and providers for prior authorizations while ensuring the accurate application of medical policies in a swift, secure, and cost-saving manner.
  2. Automate determination recommendations: Utilizing machine learning to auto-generate determination recommendations based on authorization characteristics, while preemptively identifying potential compliance or reporting issues.
  3. Enhanced Data Capture with Closed System LLMs: Automating the summarization of medical director reviews and other note compilation tasks in HELIOS for improved data accuracy and efficiency.

Moreover, thanks to the platform’s integrated interoperability solution, payors using HELIOSum get seamless UM-CM interoperability that can help them meet new CMS prior authorization and interoperability requirements.

Configurable UM Workflows

In HELIOS, the unmatched flexibility to easily adjust for evolving regulation changes comes from the platform’s highly configurable UM workflows.

Pre-built UM pathways, a configurable rules engine, and customizable workflows streamline reviews, appeals, grievances, and UM processes. payors can use HELIOS’ out-of-the-box, clinically-integrated workflows or create their own quickly and easily.

Pre-built UM pathways, a configurable rules engine, and customizable workflows automate critical processes such as approvals, determinations, triaging high-priority authorizations, turnaround times, and more. Plus, HELIOS is integrated with both MCG’s and Oputm’s InterQual clinical guidelines that can help enhance accuracy and compliance, and the platform can also use internal guidelines to support organization-specific medical policy or state guidelines. Get more information about configurable UM workflows in HELIOS >

Industry-Leading Rules Engines Improve Utilization Management

Beyond configurable workflows and AI-powered decisioning, HELIOS offers one more unique feature that other platforms can’t claim. HELIOS has the industry’s best workflow rules engine. When paired with the platform’s 90% configurability, it enables healthcare payors to easily and quickly streamline everything for UM.

From prior authorization to appeals and grievances, HELIOS’ configurable workflows and rules engine can help payors meet evolving regulatory requirements as well as internal policy and state-specific timelines.

HELIOS’s unique rules engine and configurable workflows for UM help payors achieve faster authorizations and determinations, make appeals and grievances easier to track, manage and resolve, and enable a truly connected, collaborative care approach.

Learn more about how HELIOS can help you meet new prior authorization requirements here now >



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