AI companies are leaning on partnerships for prior authorization

Early lessons are emerging as the digital health sector’s ambient AI focus shifts from clinical documentation to prior authorization.

Companies such as Abridge, Suki and Cohere say their solutions can do for prior authorization what ambient AI has done for documentation and clinician burnout.The importance of partnerships become an integral part of their efforts in this area. 

In August, Abridge announced a partnership with Pittsburgh-based insurer Highmark Health and its integrated health system Alleghany Health Network to develop a tool that would approve prior authorization requests at the point of care. Prior authorization was the logical next step for Abridge after clinical documentation, said Clinical Strategy Principal Matt Troup.

Six months in, the collaboration has shown the importance of building connections with providers and payers when developing ambient AI for prior authorization.

“[Our partnership] just gave us access to bring everyone to the table, to figure out, what we can possibly do in this space,” Troup said. “Is it actually possible to get these approvals in real-time, upstream in the conversation, if both the payer and provider are aligned on the impact that this can have in healthcare.” 

The Highmark collaboration has resulted in an ambient AI documentation platform that allows clinicians to extract relevant information from conversations with patients. It also flags when the clinician needs more information in order to ensure a procedure or treatment is approved. 

Troup said that a lot of prior authorization-related inefficiency takes place when the criteria to meet medical necessity doesn’t come up during the course of a patient visit. 

“If you can use the intelligence layer that we’re building to get that criteria met in real time, you can start to impact some of the waste that happens downstream,” Troup said.

Abridge formed a partnership with Availity in January, which Troup said would open the door for the company to create additional ambient AI revenue cycle solutions for payers. 

Cohere first teamed up with Microsoft in October to help automate prior authorization for health plans. The ambient listening function picks up important patient information to help ease the prior authorization request process. 

Matt Parker, chief product officer at Cohere, said that the company brings their knowledge of polices, health plan designs and business rules to the partnership while Microsoft has designed the interface. Parker said AI is an effective solution for prior authorization because it directly removes the administrative burden.

“AI is really good at looking at [clinical documentation] and being able to, with the right technical prompting, extract information that says, ‘For this particular procedure, I need to know X, Y and Z. I can go find X, Y and Z, where it exists in the documents,” Parker said.

Cohere has a clinical team that consists of nurses and doctors working on both the strategic and operational sides of the company. One of the biggest lessons learned was the value of leaning on this expertise.
 

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