Industry-leading artificial intelligence technology transforms health care experience for Regence members
One way we help support Regence members’ care needs is through a review process called pre-authorization (PA). Health plans use PA for some medical services before a patient can receive care using their health plan benefits. The PA process requires review of certain services for medical necessity using criteria outlined in a health plan’s evidence-based medical policy criteria. This also prevents members from undergoing unnecessary or overused health care services.
When PA is required, we work with our members’ health care providers to make sure treatment is safe, necessary and effective. At times the process may increase treatment wait times for members and create an administrative burden for their providers. In fact, Medical Economics reported PA to be a top challenge for providers surveyed in 2022.
Recently, we began rolling out a PA approval workflow using artificial intelligence (AI), a first-of-its kind in our four-market footprint. Using AI allows us to use data and technology to minimize PA wait time so the right care is delivered as soon as possible. In fact, some PA reviews are now automatically approved with little or no human interaction using AI.
“Our goal is to be an industry leader in transforming health care processes to improve care access as well as the patient and provider experience, ultimately resulting in better outcomes,” says Dr. Marion Couch, senior vice president of Health Care Services and chief medical officer for Regence “Using artificial intelligence and interoperability technology in certain PA reviews does just that by improving speed-to-care for members while reducing the burden for providers.”
Regence’s industry-leading AI PA process was developed using thousands of historical pre-authorization cases to identify patterns in required criteria for approval, evaluate those patterns in the current request, and predict the appropriateness for a future requested services when a pre-authorization request is received, yielding an automatic decision.
“AI allows for faster pre-authorization approval because it no longer needs a clinician to review each request, allowing our clinicians to spend time on more complex cases where our members need them most,” says Heidi Kriz, assistant director of medical policy for Regence. “If the workflow determines the criteria are met, the request is approved immediately and can return a decision to providers in minutes. AI will never deny a request, and our clinicians will review the suggestion and make the final determination. This is just the beginning, and we are excited for the future using AI and interoperability to further transform the health care experience”
The workflow began rolling out in March 2022, improving speed-to-care for the 3.4+ million people we serve through Regence health plans and reducing provider burdens for select medical policies.