Atlantic Health streamlines insurance authorization with intelligent automation

When the COVID-19 pandemic started, Atlantic Health System, like other healthcare providers, found itself under enormous stress. In addition to dealing with patients suffering the effects of a new virus, healthcare providers had to contend with new care protocols, staffing issues, and supplies shortages spurred by the pandemic, all of which placed additional pressure on any existing friction in healthcare administration processes.

“The pandemic and the aging population and growing population really put very high stress on every healthcare system, and Atlantic Health was no exception,” says Sunil Dadlani, chief information and digital officer and chief cybersecurity officer at the New Jersey-based nonprofit healthcare network. “You combine that with workforce shortages, supply chain shortages, and many other things that are going on.”

Atlantic Health serves a population of 6.2 million people, with more than 400 sites of care, including six hospitals, and as the organization struggled with these issues, it quickly became apparent that insurance authorization for imaging and radiology services — a foundational diagnostic step before almost any care can begin — was a bottleneck. When care is time-sensitive, any delays can affect patient outcomes.

Scheduling and receiving authorization for healthcare services has traditionally been a highly complex and manual process. Each of the more than 100 radiology practices across Atlantic Health System was responsible for its own authorization requests, which required significant investment of time and attention to administrative tasks.

“Our patients come from different backgrounds, and they have different payors. Each payor has its own formats, its own requirements, its own processes,” Dadlani says. “With the growing volume of radiology, it created a sense of urgency, because we were seeing a higher number of denials in pre-authorization. We saw a higher volume of additional documentation that was needed for pre-authorization.”

To address these challenges, Atlantic Health System undertook a project it called Prior Authorization Intelligent Automation, which has earned it a CIO 100 Award in IT Excellence.

Automating efficiency

Dadlani and his IT team collaborated with Atlantic Health System’s radiology and patient access service lines to streamline the processes involved in obtaining prior insurance authorizations through use of automation. The project team used intelligent rule-based analysis to identify services that require authorization and prioritize submitting them to payor portals. The automation polls the payor portals for updates and retrieves authorization information without the need for a human in the interaction.

By expediting the process, important procedures can be scheduled before the prior authorization process begins, meaning patients no longer have to wait to receive critical follow-up care.

Of course, with so many practices, clinicians, and team members involved in the prior authorization process, succeeding in intelligent automation was no mean feat. First and foremost, it required standardizing the prior authorization workflows unique to its more than 100 radiology practices. The practice operations, physicians, and technology teams had to develop a new prior authorization request process, which included the creation of a new centralized pre-services team to oversee prior authorizations for the entire organization.

Establishing a new pre-services team enabled the individual practices to offload the administrative burden of obtaining prior authorization, and simplified the process of training the individual practices on the intelligent automation solution. The project team, collaborating with the new pre-services team, used a series of webinars and small group sessions to help each team understand their new responsibilities and generate buy-in.

For Dadlani, the key to success was starting with a focus on the business problem, not technology.

“We started by partnering with the right stakeholders so that we could actually define the right problem,” he explains. “Instead of starting with the automation, we started with the business process.”

For the IT team, this is essential because technologies and technology vendors come and go. Dadlani notes that his team is always thinking about three things: vendor refresh, technology refresh, and skillset refresh.

“We have learned over time that there are always disruptions happening in our partner’s ecosystems,” Dadlani says. “So we are constantly evaluating the business relationships we build over the years to make sure we are best positioned for the years to come.”

Spreading success

Prior Authorization Intelligent Automation has helped Atlantic Health System reduce the amount of time it takes to submit authorizations by more than 50%, which is also 50% below the industry average. In addition, 70% of all authorizations within the radiology service line are now handled through intelligent automation and less than 1% of appointments are canceled due to denied or delayed authorizations.

“In terms of process, we were taking days,” Dadlani says. “We are at less than four minutes.”

Dadlani is now looking for ways to extend the organization’s success in automating prior authorization for radiology services to Atlantic Health System’s other service lines, like surgery and cardiology.

“We are not done,” he says. “We picked up imaging. Now we want to extend this to other areas. We have a proven use case, proven results in scaling this out at the enterprise level for radiology.”

Dadlani recommends that technology leaders seeking to implement intelligent automation in their organizations keep an open mind and be willing to fail smart, learn fast, and adapt.

“Do you have a culture of collaboration and communication? That’s very important,” he says. “You must understand the problems or the challenges your partners are having. Your mindset should be to make them successful and solve those problems.”

CIO 100, Healthcare Industry, Robotic Process Automation