Rodney's Take 7-8-24 AI Takes on Medical Coding

Beating the Codes

So, you need a knee replacement. You waited too long, and now the pain is excruciating. But you have to wait for your insurance company to provide prior authorization (PA), and neither it nor your doctor seems to be in a hurry to make that happen.

Don’t look at me; I belong to a Christian gift-sharing program (yes, it’s Affordable Care Act–approved) rather than having health insurance. While I have to pay some whopper bills up front for medical care, I can choose to get treated without waiting and eventually, I’ll get reimbursed. Now, it seems like more people are required to make their own down payments, just like me, for big-ticket procedures.

Insurance companies are requiring ever-greater numbers of PAs on ever-more types of medicines and medical procedures. Their rules change constantly. PA denials are way up, often because authorization codes are wrong or missing or doctors tacked on another billable service (a retro authorization) at the last minute.

PAs don’t have a big fan club outside the insurance industry, either from patients or from medical staff. In a Medical Economics report, doctors ranked PAs the No. 3 challenge they faced. An April 2023 study from medical generative AI platform AKASA found prior authorization (PA) the second-most time-consuming task for healthcare financial professionals. AKASA helps medical professionals maximize income by streamlining medical coding and the PA process.   

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Each time your nurse or doctor has to get a PA, it takes time away from you— 12 minutes and 7 seconds on average to submit and check the status of a PA request—and the average doctor submits 41 prior authorizations per week. It doesn’t help that we’re low on medical staff. The U.S. Health Resources and Services Administration estimates the U.S. needs over 17k more primary care doctors, 12k more dentists, and 8.2K more mental health professionals.

It’s a good bet that the growing numbers of medical AI tools will help out with such issues over the next few years. Meanwhile, chances are your care has been delayed or you can’t get treated at all for some conditions.

Everyone from the federal government and select states to various organizations has tried to help. One thing that has sped up the process is the use of electronic PAs. Another is gold carding, which, according to the American Medical Association, rewards doctors with a good track record while pushing the need for additional PAs onto “outlier” providers.

Texas was the earliest adopter. In 2022, Texas passed a gold-carding law to allow doctors with very high (90%) PA approval rates on certain procedures over the previous six months to be exempt from needing PA approval for some procedures. That sounds great… but some medical people say gold carding actually increases the PA reporting burden.

Here’s where AI could step in. A McKinsey and Company report found that AI-enabled automation could be used on up to 50% to 75% of PA tasks, boosting revenue, negating the need for additional staff, and making it so existing medical staff won’t have to learn new tools. Even now, companies like AKASA claim their AI-driven products can do all the annoying search and submission tasks related to PAs.

But I keep wondering if it’s going to end up like those phone trees you now get every time you try to contact a doctor, pharmacy, or, frankly, any other company. They don’t have all of the necessary options, and you end up wanting to talk to a human near you in a language you understand. Every time we get new tech, it seems like there’s less chance of talking to, oh, anyone who could actually solve your problem. Meanwhile, you’re stuck “pressing one” again to hear all the menu options that still don’t quite fit your needs.

How’s that knee?

Rodney and Brook

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