Laura Buckley

Last week, Elion covered the AI prior auth space for providers. This week we're looking at it from the payer side. For payers, prior authorization (PA) is a necessary burden: important for utilization management (UM) and financial planning, but a nightmare to manage. After PA requests are sent in, payers have to process the request from various channels into a case, match it with clinical criteria, validate required information, review and make the PA determination, then respond and iterate through any appeals. As payers update their procedures with new clinical evidence guidelines and new diagnostics and treatments, managing policies and creating decision trees for PA decisions requires enormous effort. Payer-facing AI prior authorization platforms have a huge opportunity to streamline these workflows by: 📒 Improving rules-engine generation and updates from unstructured policy documents and PDFs 📤 Automatically processing PA requests across all channels ✅ Matching the case to the right clinical criteria, validating data completeness, and determining if policies have been met through machine learning models and generative AI 📬 Generating decision documents and automating appeals correspondence with providers Several vendors are already making strides in AI-enabled PA for payers. Banjo Health offers tooling both for the PA request and clinical decision policy creation workflows for health plans, TPAs, and pharmacy benefit managers. basys.ai uses LLMs to offer rapid ingestion of policy documents for fast integration and up-to-date policies. Cohere Health is one of the more mature vendors in the space, and offers a variety of products for UM. Co:Helm is a generative AI platform for payers, with initial use cases around enabling UM nurses to make complex PA decisions more quickly. Finally, GenHealth.ai has built their own large medical foundation model and is using it to enable both rapid policy ingestion and PA review. We see PA as the first place where payers will incorporate advanced clinical AI. Although PA denials should never be fully automated, vendors that can drive efficiency here stand to become a core part of payers’ clinical decision-making process. --- We received a number of interesting responses last week regarding the AI prior auth space. We're continuing to dive deep here, so please reach out if you're currently investigating it and would like to discuss.

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VERY frustrating healthcare insurance cost forecast from JP Morgan! Yet complicated authorizations, time consuming denials on standard of care and growing unworthy appeals are abundant in the offices of providers and Hospitals. Please check out this report that discussed the expected costs and continued rise in insurance premium costs despite record breaking profits for the commercial insurance industry. 1. UnitedHealth Group: $22.4 billion Total net earnings in 2023 were $22.4 billion, up 11.2% year over year. UnitedHealthcare's total earnings from operations in 2023 were $16.4 billion, up 14.2% year over year. 2. CVS Health: $8.3 billion Total net income in 2023 was $8.3 billion, up from $4.3 billion in 2022. Aetna reported nearly $5.6 billion in adjusted operating income for 2023. 3. Elevance Health: $6 billion Total net income in 2023 was nearly $6 billion, up 1.6%. The insurance division reported a total operating gain of $6.9 billion in 2023, up 14.4%. 4. Cigna Group: $5.2 billion Total net income in 2023 was nearly $5.2 billion, down 23% year over year. The insurance side of the business, Cigna Healthcare, reported an operating income of $4.2 billion in 2023. 5. Centene: $2.7 billion Total net income in 2023 was $2.7 billion, up 124% year over year. In the fourth quarter, net income was $45 million, compared to a loss of $219 million year over year. 6. Humana: $2.5 billion Total net income totaled nearly $2.5 billion in 2023, down 11.3%. The company's insurance segment reported an operating income of $2.7 billion in 2023. #physicians #hospitals #healthcare #insurers https://lnkd.in/gst6CS9y https://lnkd.in/g6su6SuJ

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