Use case: Accelerated prior authorizations
Goal
A large American health insurer offering a wide range of health and life insurance benefits and services was looking to modernize its prior authorization review process (evaluating requests from members for medical services outside their coverage) to accelerate turnaround times and reduce costs.
Challenges
- Member response time delayed from cumbersome, disconnected review process
- Costly errors in prior authorization requests from manual decisions
- Expensive legacy system had limited functionality and no provider integration
- Struggled adapting to evolving care expectations and regulations
Solutions
- Built a configurable solution with business logic for prior authorization requests
- Integrated with internal and external systems for membership, eligibility, providers, and more
- Automated staff workload routing
- Captured audit history data for improved regulatory compliance
Results
- Improved member request response time from days to minutes
- Reduced approving wasteful and unnecessary services, saving millions of dollars per year
- Increased provider satisfaction
- Eliminated system downtime
