According to the American Medical Association, 1 out of 5 prescription drugs needs prior authorization. The current process to initialize prior authorization happens either during prescribing by physicians, 25% of all initiation (2022 data) or at pharmacy by pharmacists, 75% of all initiation.
When to initialize prior authorization makes a big difference.
When prior authorization is initialized during prescribing, it takes 3 steps for patients to receive medications.
1. Physicians prescribe medications and initialize prior authorization.
2. Patients go to pharmacies and pick up drugs.
3. Pharmacists dispense medication upon determinations.
When prior authorization is initialized by pharmacists, it takes 5 steps and longer time for patients to receive medications.
1. Physicians prescribe medications.
2. Patients go to pharmacies and pharmacists receive denials from health plans.
3. Pharmacists initialize prior authorization and send requests back to physicians.
4. Physicians fill paperwork, and health plans reverse denials.
5. Patients go back to the pharmacy and receive medications.
93% physicians said prior authorization caused treatment delay. Clearly, better processes reduce wait time and accelerate care delivery. Believe it or not, physicians cannot see all the rules and requirements on prior authorization on their computer screens most of the time.
Large trained Language AI model can solve this problem. The AI model can present all the rules of prior authorization to physicians, and more importantly, it can present the right rule by reading through encounter and test notes on the patient from the early part of the patient journey. The AI model can significantly streamline the current prior authorization process.
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