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About digital prior authorization
Prior authorization is a management process by which healthcare providers obtain approval from payers before delivering specific services in order to prevent lost revenue and reduce expenses.
The current prior authorization process is extremely burdensome and time-consuming–the average physician must complete 41 prior authorizations per week, which translates into about 14 labor hours for prior authorizations alone, according to a 2020 American Medical Association survey. It's also one of the most costly administrative transactions, with an average expenditure of about $11 for each request. But the prior authorization landscape is changing, and the lost time and sunk costs are decreasing as intelligent automation becomes commonplace.
While a manual prior authorization takes an average of 21 minutes, a digital transaction can be completed in about four minutes, with fewer denials and faster turnaround time.
What many of the leading solutions offer:
- Requirements identification and knowledge base
- Automated form completion
- Forms library
- Automated documentation collection
- Automated submission
- Continuous status monitoring
About this report
The Top Digital Prior Authorization Companies Report is intended to provide healthcare leaders with a broad view of the prior authorization process and showcase standout companies and solutions with proven market traction. Users can view quick summaries to help them identify which solutions might meet their needs and visit AVIA Marketplace to access detailed profiles and verified client lists, compare solutions, and generate Match Scores to narrow their selections.
This report is powered by AVIA Marketplace data, and inclusion is based on the number of verified health system clients listed for each company on AVIA Marketplace. Due to confidentiality agreements, vendors may not always be able to provide full lists of clients.
AVIA Marketplace's top digital prior authorization companies
Arrive Health, previously known as RxRevu, offers automatic electronic prior authorization alongside real-time medical and pharmacy benefit information in its Direct care access solution. Direct integrates with the EHR to present eligibility and accurate pricing information within ordering workflows, so providers and patients can have informed discussions about the true cost of care and review alternative options. Providers receive real-time notifications about coverage restrictions and Direct automatically initiates the prior authorization process to save time and effort.
Waystar’s Authorizations Suite, powered with its Hubble robotic process automation platform, does more than streamline the process–it learns with each exchange and continually adapts to shifting payer rules and requirements. The Hubble platform reviews EHR orders in real time, initiates the prior authorization and streamlines the submission of required documentation, and automatically monitors status and pushes details to the EHR or practice management system. The Authorizations Suite is part of Waystar’s full revenue cycle platform, which includes an array of financial clearance tools, claim management, revenue capture, denials management, and more.
Experian Health designed its Authorizations solution to guide providers and support staff through the prior authorization process with minimal manual involvement, automating everything from inquiries to status monitoring. Authorizations pulls real-time prior authorization requirements from its dynamically updated knowledge base, automates submissions, facilitates submissions with an exception-based workflow, and identifies variances to prevent denials and appeals.
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, while creating a centralized communication hub to capture faxed medical necessity documentation and phone exchanges with payers.
Upfront's mission is to ensure all patients get the care they need and its platform proactively engages patients through personalized omnichannel and bi-directional communication. These communications leverage demographic, socioeconomic, behavioral, psychographic and patient-reported data to tailor content to each patient based on their needs and motivations. This helps them understand their coverage and financial responsibilities while reducing billing staff workload. Providers can send automated notifications when prior authorizations or co-pays are required, supply Explanation of Benefits resources and keep patients up-to-date on their costs and insurance claims.
R1 RCM’s Entri Book patient experience solution is designed to provide greater transparency to patients while reducing administrative burdens and optimizing resources. Entri Book includes automatic processes to validate insurance and check eligibility, along with a prior authorization tool that utilizes intelligent automation and highly skilled services to facilitate quick responses. Other Entri Book tools include capacity optimization, flexible scheduling options, integrated order management, and communication tools for providers.
Change Healthcare’s eligibility and patient access solution allow providers to efficiently obtain pre-service authorizations while keeping patients informed about their financial responsibilities. The software automatically determines if prior authorization is required and on-file with the payer, and provides options for manual intervention to ensure that critical steps are not overlooked. Change continually monitors pending pre-authorization decisions and automatically pushes new information to EHRs, all while capturing audit trails to reduce authorization-related claim denials. Providers also have the option to generate Advanced Beneficiary Notices, which explain anticipated charges to patients before care delivery.
Administrative errors and missing information are among the most common reasons for prior authorization denials. Olive’s end-to-end prior authorization solution streamlines the processes with more efficient workflows and AI-powered automation that save staff time and reduce requests for additional documentation and related appeals. With a database that includes medical necessity criteria for tens of thousands of procedures, Olive recommends and automates specific clinical bundles for individual requests. The result: More first-pass approvals and fewer denials.
Cohere Health’s Unify platform is a configurable end-to-end prior authorization solution that the company says speeds up access to care by 70 percent with 63 percent lower denial rates. The Intake solution digitizes requests from all sources and includes intelligent form completion and portal access, and the Decisioning module scans requests for completion and conducts automated clinical reviews. Cohere’s utilization management solution offers additional insights to inform care plan decision-making and lower overall costs.
Rhyme’s comprehensive prior authorization solution bypasses phone calls, faxes, and portals to directly connect providers and payers and speed up the pre-service authorization process. Formerly known as PriorAuthNow, Rhyme integrates with existing clinical workflows and facilitates faster payer/provider communications through a shared knowledge base. Instead of the standard prior authorization process, providers can receive real-time authorizations through meaningful interactions–without the endless back-and-forth.
Find your new prior authorization solution.
Prior authorizations are some of the most frustrating, time-consuming, and costly administrative tasks that providers must complete, with most physicians submitting dozens each week. But electronic prior authorization solutions and intelligent automation drastically reduce the time and effort required for each transaction with tools like automated eligibility checks, forms completion, and continuous status monitoring to increase first-pass approvals and streamline appeals and documentation.
Visit AVIA Marketplace to explore the companies listed in this report and thousands of other digital health companies and solutions. You’ll find verified client lists, use cases, differentiators, and more to help you streamline the vendor selection process and identify companies that can fulfill the unique needs of your health system.
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