AVIA Marketplace is the leading online resource for accurate, unbiased information about digital health companies and solutions. Our goal: To empower hospitals and health systems with the information they need to match with vendors who can meet their unique needs. We asked the top companies in the prior authorization space about their solutions and what they think the future of digital health looks like. No sponsored content or advertorials—just transparency and insights that decision-makers can use.
With its end-to-end automation platform VALER, Voluware offers a unified solution for prior authorizations, referrals management, and eligibility and coverage. VALER fully automates prior authorization submissions and includes a comprehensive form library and real-time payer information and status monitoring. The cloud-based solution covers all service types, including professional, facility, technical, pharmacy, and DME authorization workflows, and creates a centralized communication hub to capture faxed medical necessity documentation and phone exchanges with payers.
Co-founder and CEO Steve Kim, M.D., founded Voluware to solve issues related to highly manual prior authorization, referral, and eligibility workflows that he encountered during his time practicing pediatric surgery at Children’s Hospital Los Angeles. Dr. Kim formerly worked as an assistant professor at the University of Southern California Keck School of Medicine, where he also served as the director of clinical research informatics for CHLA. He received his undergraduate degree from Yale University, attended medical school at Cornell University Medical College, earned a Master of Science in Clinical Epidemiology from the University of Pennsylvania, and an MBA from the University of Southern California Marshall School of Business.
Q: Can you tell us about your company and the challenges you are solving within the prior authorization space?
A: Voluware was founded with a mission to ensure patients receive the care they need without unnecessary delays created by today’s manual administrative workflows. Our cloud-based platform, called VALER®, standardizes, streamlines and automates prior authorizations for health systems, hospitals, ambulatory clinics, and payers. Voluware’s workflow-centric and customized approach to each client’s unique prior authorization needs accelerates time to results and reduces barriers to access.
Q: How does your company differentiate from other vendors in the same category?
A: Voluware differentiates itself from other vendors in the prior authorization space with our understanding of both the deep technical complexities and the practical workflow realities that clients face in order to function in today’s evolving prior authorization environment. Our VALER platform was built from the ground up with not only the end user in mind, but also with the understanding that each authorization represents a patient waiting for care.
VALER is the only solution in the market that robustly automates prior authorization submissions across all payers and service lines. While most other vendors primarily offer only authorization status verification across a few select payers for a few select services, VALER provides one source to comprehensively submit and verify authorizations across over 75 payer web portals with more than 1,000 payer fax forms.
Our platform is not a one-size-fits-no-one approach to prior authorizations. We understand that each client brings its own unique mix of complex payer-specific requirements, inherent EHR limitations, and myriad workflows that aren’t necessarily compatible with a single approach. VALER tailored to each client’s broad organizational workflow needs in order to maximize workflow automation and eliminate manual and duplicative data entry wherever possible.
VALER also rapidly adapts to changes in payer rules or requirements–a frequent occurrence, as anyone who has dealt with prior authorizations understands. In addition to the ability to centralize and maintain fragmented payer authorization workflows, VALER can quickly update and incorporate payer workflow changes at runtime, with no long waits for software upgrades or support tickets.
Lastly, our clients enjoy unparalleled real-time visibility around prior authorizations. Over 80 percent of prior authorization workflows are completed manually, which means that it is virtually impossible to clearly grasp the root causes of bottlenecks and costly errors. But because prior authorizations are submitted and verified in VALER across all payers and service lines, clients have a clear view of every aspect of the prior authorization life cycle, from provider order to closed out prior authorization back in the EHR. We also provide real-time data and custom reporting on staff productivity, payer turnaround times and payer responses, along with detailed audit trails and activity logs.
Q: What are some of the biggest changes your company has seen around how health systems are approaching prior authorization, given the changes in the landscape over the past couple of years?
A: With over a decade of experience building prior authorization workflow automation solutions for patient access teams, the most significant changes that we’ve seen in how health systems are working to address prior authorizations have been the increased adoption of robotic processing automation (RPA) and labor offshoring/outsourcing. Each approach has its merits, but there are also significant issues that limit efficiency and effectiveness.
With RPA/low code options for building automations, client teams can configure automations for highly standardized and repetitive tasks with good results. But the nature of prior authorizations is non-standardized, complex, and constantly changing, which is where problems arise. Configuring and maintaining these automations requires time, effort, and financial investment, and the complexity of these tasks can quickly consume client teams and negate any efficiency gains.
With respect to outsourcing/offshoring as labor arbitrage, organizations can have difficulties understanding local payer rules, idiosyncrasies, and nuances when dealing with specific payer prior authorizations. That disconnect between providers and offshore patient access staff can inadvertently add delays and frustration to prior authorization workflows and erode or undermine the cost savings associated with labor arbitrage.
VALER bypasses these issues and empowers existing patient access teams to do more. We eliminate unnecessary manual tasks and data entry and leverage staff experience, relationships, and knowledge.
Q: What does an ideal client look like? How are health systems best organized for success in standing up prior authorization and adjacent capabilities?
A: The ideal VALER client doesn’t necessarily fit with a specific structural mold. Our most successful clients are organizations that follow a few general principles in their preparation and approach to implementation:
- Understand what current prior authorization workflows look like across the organization. Prior authorization workflows are incredibly fragmented and highly variable in nature. We frequently find significant variation in how prior authorizations are processed, not only from team to team, but also between individual staff members. This often reflects a lack of standardization, transparency, and education when it comes to payer-specific authorization requirements. Organizations should identify best practices and move to standardization. Ideally they take the time to develop process maps and create clear roles and responsibilities, which can decrease friction and build accountability.
- Understand the time, effort, and cost involved with prior authorizations in order to prioritize efforts. Identifying overall costs for managing prior authorizations across various service areas can help organizations gain a clear understanding of where to start and how to maximize ROI and minimize time to value. While measuring this burden, organizations should consider the operational staff time and costs that the prior authorization process incurs and the denied dollars attributable to prior authorization errors.
- Create a clear roadmap for transforming prior authorizations. Working to define a clear roadmap for implementation has been a hallmark for success with VALER clients. Frequently, we would start VALER with centralized patient access teams with a high volume of prior authorization submissions and verifications–we typically see this in health systems with a centralized team that handles high volume diagnostic imaging and/or surgery/procedure authorizations. In our experience, looking at areas of high impact first and establishing early wins with automation leads to increased engagement and user adoption across other teams.
- Do your homework–listen to your staff to get their input and buy-in. Listening closely to key staff members who actually work on securing prior authorizations is critical to successful implementation. We’ve seen many prior authorization solutions that apply new technology (AI, machine learning, or RPA) to the problem with no meaningful understanding of the practical workflow implications involved. Organizations that take the time to vet solutions and invite the feedback of frontline staff are much better positioned to understand the opportunities and limitations of technology. Involving user input better aligns expectations and fosters engagement that can better drive meaningful adoption and results.
Our most successful clients are the ones that thoughtfully approach problems, identify opportunities, and develop clear plans with VALER. The Voluware team can also lend its expertise to assist organizations with successful planning and implementation.
Q: What measurable outcomes have you seen from your clients?
A: VALER clients have seen many benefits related to their prior authorization workflows. The team at Oregon Health & Sciences University (OHSU) reported the following results with VALER for their central patient access team’s prior authorization workflows:
- Staff spent 45 percent less time processing prior authorizations (including submission, verification, and pushing back to the EHR)
- Overall authorization volume increased 11 percent with the same or smaller staff
- Authorization days out metric increased from 5 to 13 days, with fewer cancellations and reschedules
Other VALER clients have similarly experienced a 40-50 percent reduction in overall prior authorization staff processing times, doubling of staff productivity, and higher satisfaction with prior authorization workflows.
With respect to denials related to prior authorizations, an academic medical center client reported a reduction in first pass denial rates of more than 50 percent within the first year of utilizing VALER.
Q: What major functional enhancements and/or product investments are you making in the near term to keep up with the evolution of automation generally?
A: VALER has developed and is currently implementing a pilot with a major national health plan for application programming interfaces (APIs) to provide the following real-time prior authorization functionalities:
- Pre-check to determine PA requirements for medical, radiological, DME, Part B drugs and home health care services
- Electronic submission of PA requests directly to payer
- Auto-approve requests when available from payer
- Electronic notification and information about authorization adjudication
- Eligibility verification
- Referral status checking (if required for authorization)
Q: How is your company partnering with clients as reimbursements and use cases shift?
A: At Voluware, we pride ourselves on being good partners with our provider client teams that work on the frontlines. Our VALER platform has always been custom designed with client team workflows in mind, with runtime-changeable architecture that continuously adapts and evolves to meet new use cases with respect to payer authorization requirements and workflow changes. In this way, we provide clients with a flexible system to keep pace with an ever-changing reimbursement environment.
Q: What are the biggest opportunities health systems should be thinking about this year when it comes to automation?
A: Health systems are facing staffing shortages in the administrative ranks as a result of the pandemic and the subsequent “Great Resignation,” which means that health systems need to focus on targeted automation opportunities with the highest return on investment. Prior authorization submission and verification workflows are a high-value opportunity for workflow automation with significant operational impact for depleted patient access teams, with the added benefit of fewer costly downstream denials and avoidable write-offs. When health systems invest in the right technology platforms to support automated prior authorizations, they can empower staff to improve productivity, address key bottlenecks to patient access, and mitigate lost revenue.
Q: How do you see the prior authorization space evolving in the next two to five years and beyond?
A: Healthcare organizations will continue to advocate for CMS regulations that require payers to transition from antiquated workflows to electronic prior authorizations with more automation. We can already see this momentum with proposed CMS rule changes regarding prior authorization and federal and state legislative efforts to improve standardization, transparency, and accountability. Greater regulatory scrutiny will target not only health plans, but certified EHRs as well in order to promote interoperability and facilitate electronic exchange and adjudication between payers with application programming interfaces (APIs). Compliance will take time and significant labor and investment for both payers and providers to achieve real-time request and adjudication of prior authorizations.
Today, VALER provides a bootstrapped authorization clearinghouse that already allows for electronic exchange and meaningful automation of existing manual workflows. Meanwhile, we’re hard at work building a roadmap for the future of real-time APIs for all prior authorizations across all payers.
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