CHICAGO — Health Care Service Corporation (HCSC) is responsibly integrating both artificial and augmented intelligence to positively transform the prior authorization experience. The company operates health plans in Illinois, Montana, New Mexico, Oklahoma and Texas, providing benefits for 18 million members.
“Prior authorizations are an important way to ensure members receive the right care at the right place at the right time and to avoid duplicative, unnecessary or wasteful services,” said HCSC Chief Clinical Officer Dr. Monica Berner. “We recognized a few years ago the need to make it quicker and easier for providers and members to get the answers they need and took advantage of emerging technology to develop a suite of tools that simply work better for everyone involved.”
HCSC, which received over 1.5 million prior authorization requests in 2022 alone, has now expanded use of a proprietary augmented intelligence tool that streamlines and accelerates the prior authorization (PA) process up to 1,400 times faster.
The tool was first developed in 2021, then piloted with specialty pharmacy and behavioral health in 2022. In 2023, use of the tool was expanded to include requests for inpatient acute care, long-term acute care, inpatient rehabilitation, skilled nursing care, outpatient and inpatient hospice care, home health and outpatient services.
The prior authorization tool streamlines the submission process and provides auto-approvals when critical criteria are met. By asking providers the precise number of questions required to evaluate and expedite claims, it helps ease the administrative burden on providers and their staffs — taking six minutes, on average, to submit a request.
Approvals are delivered nearly instantaneously, which previously could take as long as 14 days. During the pilot phase, speed approvals were granted 80% of the time for behavioral health decisions and 66% for specialty pharmacy decisions.
By triaging and approving requests that require minimal information, the technology frees up clinical staff for review of more complex requests. No prior authorization requests are denied using the tool — they are only approved or advanced to a hands-on review by an HCSC clinician.
HCSC also has evolved its artificial intelligence (AI) capabilities to improve the speed of prior authorization approvals. The company designed proprietary algorithms that approve care for member treatments almost instantly. The algorithm references historical authorizations and claims and recognizes what data is required to authorize treatment within seconds.
The AI technology is used for 93% of HCSC members for a limited number of procedure codes. The company’s next phase will involve expanding the number of codes included. With this technology, no requests are denied without a human in the loop.
HCSC also regularly audits the procedures that require prior authorization. Since 2018, the company has eliminated prior authorization requirements for nearly 1,000 procedure codes, part of an ongoing initiative to lay the groundwork for further innovations.
Additionally, since January 2022, HCSC has invited select health care facilities in Illinois to participate in a “Gold Card” program. Those facilities must meet criteria that identifies their adherence to evidence-based national criteria standards of care. In return, their prior authorization requests for fully insured members are auto approved if received within three days or less of a requested inpatient procedure. In 2022, more than 14,000 prior authorization requests were auto approved for the nine facilities currently participating in the program.
“We recognize that providers and payers need to work together to help make the health care process easy to use and effective to benefit our members,” said Dr. Berner. “For us, ‘fixing’ prior authorization so it works better for everyone isn’t a new idea and we’re happy to see others in the industry moving in that direction as well.”
About Health Care Service Corporation
Health Care Service Corporation is the country's largest customer-owned health insurer, with 18 million members in its health plans in Illinois, Montana, New Mexico, Oklahoma, and Texas. A Mutual Legal Reserve Company, HCSC is an independent licensee of the Blue Cross and Blue Shield Association.