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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.
We've seen a steady shift in the industry–the results are undeniable. Health systems are turning increasingly to digital prior authorization solutions that leverage robotic process automation (RPA) to generate, submit, and monitor the status of prior authorization requests. Organizations doing this well are seeing millions of dollars in additional revenue.
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
Introduction to the report
The Top Prior Authorization Companies Report is a resource designed to guide healthcare professionals in their quest for exceptional operational and customer oriented solutions. This report offers perspective on prominent provider documentation companies as reflected in the client reviews gathered on AVIA Marketplace and presents a selection of leading-edge solutions and companies.
This report is organized around client reviews that provide insight into the impact these solutions have had with the organizations they work with and include concise summaries that could assist in pinpointing solutions tailored to your unique needs. Our AVIA Marketplace serves as an additional resource, facilitating access to detailed company profiles, verified client lists, comparison of various solutions, and Match Scores to streamline your selection process. For even greater depth, AVIA experts are available through a Marketplace Product Review (for digital health solutions) and AVIA Membership (for hospitals and health systems). Ready to learn more? Send us a note!
Our methodology
The data that powers this report stems directly from the AVIA Marketplace, informed by reviews and by the number of verified health system clients associated with each company featured in the marketplace. In observance of confidentiality agreements, the complete client lists may not always be available from vendors.
Please note that the data presented is dynamic and subject to change over time. Therefore, we advise that decisions drawn from this information should be made judiciously, backed by thorough consideration.
AVIA's perspective and report limitations
Please note that this information does not reflect the opinions or views of AVIA as a whole, or AVIA Advisory Services. Rather, it reflects data captured on AVIA Marketplace at a point in time. This data is subject to change over time.
We at AVIA acknowledge the diverse strategies hospitals employ when selecting technologies. The reviews herein can offer valuable insight, but we also encourage considering other factors, like EMR integration, experience with clients similar to your organization, or overall market presence, which may prove pivotal in decision-making. We endeavor to provide a comprehensive analysis on these other aspects as well.
Our unique Product Grid, powered by our proprietary Match Score, is a useful tool to consider in your evaluation process. This methodology ensures that the products featured not only meet the buyer’s specific requirements but also exhibit solid market establishment.
Top-rated prior authorization companies
The top-rated prior authorization companies were the most-reviewed within their product category. Companies in this section have all received the “Top-reviewed” recognition and the order does not indicate a ranking.
5.0
Make your operations more efficient: With Passport Authorizations, inquiries take place without user intervention, as does status monitoring. Submissions guide staff through the workflow, auto-filling all information Experian Health has received and prompting users only if their involvement is required. Access the industry’s most complete payer database: Experian Health’s pre-authorization knowledge base stores and dynamically updates payer prior authorization requirements. Your staff can check whether prior authorization is required for a particular procedure or service, and the knowledge base automatically responds to queries with information needed.
5.0
Waystar delivers innovative technology that simplifies and unifies healthcare payments. The company’s cloud-based platform helps healthcare providers across all care settings streamline workflows, improve financial performance and bring more transparency to the patient financial experience. Waystar solutions have been named Best in KLAS or Category Leader by KLAS Research 16 times (across multiple product categories) and earned multiple #1 rankings from Black Book. The Waystar platform is used by more than half a million providers, 1,000 health systems and hospitals, and 5,000 payers and health plans—and integrates with all major hospital information and practice management systems. On an annual basis, Waystar’s AI-powered solutions process $5B in patient payments, generate $4B in out-of-pocket estimates and process claims representing approximately 40% of the U.S. patient population.
5.0
Voluware provides innovative, cloud-based workflow optimization and automation solutions for administrative healthcare transactions. Our VALER platform streamlines and automates prior authorizations, eligibility verification, and referrals document management in one, easy-to-use workspace. VALER eliminates paper fax and integrates with payer web portals to automate prior authorizations. VALER improves office staff productivity and reduces the cost of managing prior authorizations. VALER eliminates manual data entry errors with prior authorizations that impact the revenue cycle. VALER delivers the benefit of automated electronic transactions today with zero client installs and zero interoperability requirements.
5.0
R1 RCM is a leading provider of technology-driven solutions that transform the patient experience and financial performance of healthcare providers. R1’s proven and scalable operating models seamlessly complement a healthcare organization’s infrastructure, quickly driving sustainable improvements to net patient revenue and cash flows while reducing operating costs and enhancing the patient experience.
5.0
Cohere Health is a clinical intelligence company that provides intelligent prior authorization as a springboard to better quality outcomes by aligning physicians and health plans on evidence-based care paths for the patient’s entire care journey. Cohere’s intelligent prior authorization solutions reduce administrative expenses while improving patient outcomes. The company is a winner of the TripleTree iAward and has been named to both Fierce Healthcare’s Fierce 15 and CB Insights’ Digital Health 150 lists. Cohere’s investors include Flare Capital Partners, Define Ventures, Deerfield, Polaris Partners, and Longitude Capital.
More digital prior authorization companies
Companies in this section did not have any reviews on AVIA Marketplace at the time of publishing. However, based on the number of verified clients we were able to gather, we include them here as other prior authorization companies to consider. They are listed in alphabetical order.
Adonis
Adonis fosters unparalleled revenue outcomes that improve efficiency, reduce costs, and increase revenue. Our partnerships are forged in the commitment to long-term financial success. Whether you're a provider with an internal billing team or you outsource your RCM operation, we're prepared to meet you where you are to improve your billing and collections outcomes.
Agadia
Agadia is a leading healthcare management technology company addressing the evolving needs of the managed care market with a suite of utilization management solutions in electronic prior authorization, MTM, part d star ratings & adherence, and formulary benefit design. Used by the nation’s largest health plans and PBMs, Agadia’s advanced technology solutions help drive operational efficiency, appropriate utilization, compliance, and profitability.
Akasa
AKASA is the leading developer of AI for healthcare operations and the revenue cycle. We scale human intelligence with leading-edge AI and ML trained on customer data to learn unique systems, continuously adapt to changing environments, and deliver comprehensive automation for complex workflows. Our platform is used by more than 475 hospitals and 8,000 outpatient facilities. Step into the future of healthcare with AKASA.
Apprio
We’ll partner with government and healthcare organizations to provide solutions that improve operational and financial performance while positively impacting patient satisfaction.
Arrive Health
Arrive Health is a healthcare technology company dedicated to putting the needs of patients and providers first. We improve access to the most affordable, quality care by delivering accurate, patient-specific cost and coverage data to providers, care teams, and patients. Collaborating with premier health systems, pharmacy benefit managers, payers, and healthcare IT vendors, Arrive Health is clearing the way for better health by reducing friction in care workflows and enabling meaningful conversations about access to care.
Availity
Availity, L.L.C. provides Internet-based health information exchange services. It optimizes the flow of information between health care providers, health plans, and other health care stakeholders through an Internet-based exchange. The company offers commercial and government health plan transactions; and CareRead, which swipes patients' magnetic stripe-enabled member ID cards through a three track card reader connected to the computer to automatically populate the fields on Web transaction pages. It also provides CareProfile, which allows to access electronic health records; patient communication, which connects physicians and patients online, and supports patient-initiated appointment and referral requests; and CarePrescribe, an electronic prescribing solution that provides access to up-to-date patient specific medication history and coverage, therapeutic equivalent and lower cost alternative options, and real-time drug interaction checks. In addition, the company offers CareCost Estimator, which determines a patient's financial responsibility in real-time at the point of care; and CareCollect, which collects patient's responsibility through a card swipe, including combination member ID cards for high deductible plans, debit cards, and credit cards. It serves various health care providers, including physician offices, hospitals, integrated delivery networks, pharmacies, laboratories, imaging centers, and other ancillary providers. Availity, L.L.C. was founded in 2001 and is based in Jacksonville, Florida.
basys.ai
basys.ai is a Harvard-based company using generative AI to streamline prior authorization and utilization management for health plans.
BirchAI
State of the Art Natural Language Processing for payers and providers. Our technical founder was a top researcher at Facebook AI Research, and our team is backed by the leading NLP research institute in the country, The Allen Institute for Artificial Intelligence. Automated processing of paper-based prior authorizations. We are able to ingest any paper form, semantically understand the content, extract entities, and feed those to your downstream systems via API. Our end-to-end proprietary pipeline is tuned to the language and processes of healthcare, insurance and banking. The result? Consistent quality that is better than human.
Change Healthcare
Change Healthcare is inspiring a better healthcare system. We are a leading independent healthcare company that provides data and analytics-driven solutions to improve clinical, financial and patient engagement outcomes in the U.S. healthcare system. Our comprehensive suite of software, analytics, technology-enabled services and network solutions take costs out of the healthcare system by driving improved results in the complex workflows of payers and providers by enhancing clinical decision-making and simplifying billing, collection and payment processes, and enabling a better patient experience. We are creating a stronger and more efficient healthcare system that enables better patient care, choice, and outcomes at scale.
Digital Blue
Digital Blue is a healthcare consulting and solutions company focused on improving lives through optimized business performance. Our services and solutions empower leaders across the healthcare ecosystem to eliminate inefficiencies, increase productivity and improve patient satisfaction. Client benefits include; increased revenue, reduced operational cost and administrative burden, and improved quality of care.
eBlu Solutions
eBlu Solutions is the only single portal software solution to verify medical benefits and prior authorizations for specialty medications.
eviCore healthcare
eviCore healthcare offers proven, diversified medical benefit management solutions that help clients reduce costs while increasing quality of care for their members. The company provides these solutions to managed care organizations and risk-bearing provider organizations serving commercial, Medicare and Medicaid populations. Powered by a team of specialized medical professional resources, extensive evidence-based guidelines and advanced technologies, the company supports clients by ensuring the right evidence-based care is delivered at the right time to the right patient at the right site of care.
Infinx
Get faster prior auth approvals using artificial intelligence and automation with exception handling by specialists.
MCG Health
MCG Health, part of the Hearst Health network, helps healthcare organizations (in both the government and private sectors) implement informed care strategies that proactively and efficiently move patients toward health. MCG’s transparent assessment of the latest research and scholarly articles – along with data analysis – gives patients, providers, and payers the vetted information they need to feel confident in their care management decisions.
PatientBond
PatientBond’s cloud-based, digital health platform automates patient engagement and care coordination with two-way communications, response tracking and real-time adjustment & optimization. PatientBond offers solutions to tackle many business and clinical challenges, including Healthcare Consumer Awareness/Marketing, Pre Visit, Point of Care, Patient Loyalty and Patient Collections for Health Systems, Physician Practices, Urgent Care Centers and Payers. PatientBond personalizes communications based on patients’ motivations and channel preferences using a proprietary psychographic segmentation model developed by healthcare consumer experts from P&G, the worldwide leader in consumer products and advertising. PatientBond enables you to activate desired patient behaviors to increase revenue and volume while ensuring cost avoidance and savings.
Rhyme
Prior authorization, minus the frustration. Rhyme connects payers and providers intelligently inside the prior authorization workflow, reclaiming the time lost on back-and-forth efforts and returning it to the patient. Join the largest integrated prior authorization network in the country!
Vital Data Technology
Vital Data Technology empowers health plans to continuously improve outcomes, accelerate compliance and control costs. Vital Data’s Affinitē™ platform unifies formerly siloed data and leverages artificial intelligence and machine learning to drive actionable interventions. The platform’s modules include: Affinitē™ PlanLink™ for real-time CareFlow™ automation and case management for stakeholders throughout the care continuum; Affinitē™ ProviderLink™ for prioritized, actionable patient interventions; MyVitalData™ for mobile app member engagement; Affinitē™ Quality for optimization of quality management and HEDIS® performance, and Affinitē™ Risk for Hierarchical Condition Category (HCC) risk adjustment. Vital Data Technology is trusted by health plans nationwide across Medicare Advantage, Medicare, Medicaid, commercial and self-funded adult and pediatric populations and has received NCQA HEDIS® Certification for five consecutive years.
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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