At Becker’s Hospital Review’s 2023 Payer Issues Roundtable, Olive’s UM Business Unit, which is now part of Availity, sponsored an executive roundtable to explore how AI and clinical data can streamline utilization management and create a foundation for broader healthcare transformation efforts. Led by Matt Cunningham, Executive Vice President, Product, leaders in attendance from health plans across the country shared their thoughts and engaged in an exciting discussion.
Four key takways were:
- AI is more than a single technology. AI isn’t simply robotic process automation, natural language processing (NLP) or statistical modeling. NLP, for example, can surface words, but it can’t interpret them. An implication in a healthcare setting is that NLP could find data related to A1C scores, but it won’t be able to isolate trends in the data. “True AI, when used well, takes advantage of multiple technologies. It thinks as a human, helping you make decisions and move forward with your business,” Mr. Cunningham said.
- With AI, the healthcare sector can practice better medicine and more effectively engage patients. In the next few years, healthcare organizations will be using AI to automate workflows, enabling employees to operate at higher capacity levels. “There’s an opportunity here to restore the human touch, not just the artificial touch,” Mr. Cunningham said.
Experts believe that those organizations that vigorously apply AI over the upcoming decades will dominate their industries. To make the AI journey more successful, a recent Harvard Business Review article recommended that organizations utilize a technology partner, apply AI throughout the enterprise, integrate AI solutions into workflows and become more data driven.
- Utilization management is the on ramp to the clinical data highway. Utilization management (UM) is the only lever that allows payers to mandate the collection of data across all programs. The current approach to UM, however, has many flaws. Most decisions are rendered with no clinical data and the process creates heavy network abrasion.
In contrast, the UM Solution collects clinical data, scores it against medical policy and automates UM workflows. “By using a clinical data-first approach, you can create a very different experience,” Mr. Cunningham said. In about 80 to 85 percent of cases today, prior authorizations are approved. If you can automate that work, human intelligence can focus on the 15 to 20 percent of cases that are complex and need a more thorough review. Our philosophy is to use UM as the foundation for building a clinical intelligence platform that enables healthcare organizations to make decisions based on clinical data and drive deeper insights from the data.
- The UM Solution reduces UM turnaround time from days to seconds. A payer recently implemented the UM Solution to support three programs that account for the majority of the organization’s prior authorizations. 78 percent are resolved without human touch. “The average turnaround time used to be 2.5 days; now it’s a matter of seconds,” Mr. Cunningham said.
As healthcare continues to rapidly evolve, the organizations that thrive will be those that use AI effectively throughout the enterprise. The UM example shows what is possible when using AI and clinical data to dramatically improve UM efficiency and the manual labor associated with prior authorization.
UPDATE: This Roundtable took place prior to the Availity acquisition of Olive’s UM business. Learn more about the acquisition here: Availity Acquires Utilization Management Solution and Business Unit from Olive.
