Foreword

The healthcare industry is witnessing a significant shift in the application of artificial intelligence (AI), particularly in utilization management (UM) and claims processing. While recent headlines have highlighted the controversial use of AI for automated claim denials, forward-thinking organizations like HealthHelp are focusing on leveraging AI for faster, more efficient approvals. HealthHelp’s AI solution enables immediate approvals with fast information gathering ensuring patients can begin treatment without delays. In complex cases where immediate auto-approval is not appropriate, our AI process also expedites outreach by HealthHelp specialists to treating providers, offering proactive education on evidence-based treatment pathways to foster collaboration for optimal patient outcomes.

The Rise of AI-Driven Denials

Recent reports have shed light on the increasing use of AI by major insurers to deny claims:

• Major insurers have faced scrutiny for claim denial rates, up significantly from previous years.
• The American Hospital Association reported a 20% increase in claim denials over the past five years.
• Prior authorization and UM contractors for insurance companies have also faced scrutiny of automated PA denials on behalf of insurers.

This trend has led to legal challenges, with lawsuits alleging that AI systems are overriding physician judgments and denying necessary care.

HealthHelp’s Perspective: AI for Faster Approvals

HealthHelp recognizes that while AI-driven denials are garnering negative press, the technology itself is not the issue. The problem lies in its application. We understand that:

• Denials are not a sustainable solution for effective UM programs.
• AI can be extremely beneficial when used to gather information for faster approvals.
• Clinically superior guidelines should be the foundation of AI-driven decision-making.

Our focus is using AI tech to remove roadblocks and move to a fast pass of needed healthcare treatment approvals and an expedited, proactive HealthHelp expert outreach and education of ordering providers in complex cases.

Benefits of AI To Accelerate Approvals

When applied correctly, AI can revolutionize the approval process and expedite needed care through the following methods.

• Rapid Data Analysis: AI can quickly process vast amounts of medical information, expediting the review process.
• Pattern Recognition: Advanced algorithms can identify trends and patterns that support faster, more accurate approvals.
• Automated Information Gathering: AI can efficiently collect and organize EMR relevant patient data, reducing manual work and speeding up the approval process.

HealthHelp’s Approach to AI in UM

HealthHelp is committed to using AI responsibly to enhance patient care and streamline the approval process:

• Clinically-Driven AI: Our AI systems are built on robust, superior clinical guidelines.
• Physician Collaboration: While AI assists in data gathering and analysis, if a case cannot be auto-approved, any further decisions would involve human clinical expertise and proactive outreach to care providers.
• Continuous Learning: Our AI systems are designed to learn and improve, adapting to new medical evidence and best practices.

The Future of AI in Healthcare

As the industry moves forward, the focus should shift from using AI for denials to leveraging it for more efficient, patient-centric care:

• Predictive Analytics: Using AI to anticipate care needs and proactively approve necessary treatments.
• Enhanced Collaboration: AI-driven systems that facilitate better communication between providers and peer reviewers.
• Personalized Care Pathways: Utilizing AI to spot cases where human clinical experts should be involved to support tailored treatment plans that are more likely to improve patient outcomes.

Summary

While AI has faced criticism for its role in automated denials, HealthHelp recognizes the tech has the ability to transform healthcare for the better when used to support trusted and reliable provider treatment practices. By focusing on using AI to gather information for faster approvals based on superior clinical guidelines, we can improve patient outcomes, reduce administrative burdens and cost by fostering expedited authorizations. Focus can then be directed to highly complex cases where we can provide proactive peer support to treating physicians on proven and up to date care protocols.

About HealthHelp

HealthHelp, a division of WNS, is a trusted healthcare advisor for health plan’s clinical programs. Our unified suite of solutions simplifies medical complexity and workforce challenges and enhances provider relations and member journeys.

Our uniquely designed UM and clinical solutions were developed to fit into health plans existing clinical programs to advance outcomes and success. We work in partnership to understand health plan commercial and Medicare clinical programs and determine where our solutions can advance outcomes and lower cost. There is no one size fits all, and we know how to build the best solution for a specific health plan’s needs.

Why Work With HealthHelp?

• Clinically Superior
• Collaborative
• Unmatched Expertise