Becker's ASC Review

expedite prior authorizations has led to a concerning surge in denials, impeding patient access to care. We have yet to see if payers will continue to incorporate AI to meet the CMS Prior Authorization Rule requirements, such as sending decisions for urgent cases within 72 hours. Although Cigna and UnitedHealthcare announced the elimination of 20-25% of prior authorizations for non-urgent medical services and procedures in 2023, this move came aer legal actions were taken against the companies for their use of AI-driven authorization tactics. Humana, the latest Medicare Advantage payer embroiled in an AI-related class action lawsuit, faces criticism for cutting payments related to rehabilitation care for beneficiaries. UnitedHealthcare confronts similar accusations from the families of two deceased Medicare Advantage patients who died aer being denied coverage for essential post-acute care, and Cigna is under scrutiny for relying on AI technology to reject hundreds of thousands of claims without physicians opening or reviewing patient files. ere's more technology and science behind revenue cycle management now than ever before, and the results from pending class action lawsuits could determine the role of AI in prior authorizations and claim denials for years to come. While we wait for the impact of these lawsuits a combination of machine learning, AI, and human intervention can enable templated, logical rebuttals and automated responses to help address these challenges. When we predict what a payer's response will be, we can prepare for all possible outcomes ahead of time. David's Next Move Against Goliath on the Authorization Battlefield Prior authorizations were meant to prove medical necessity, to serve as a checks and balances system, and to ensure doctors are ethically prescribing the right treatment so patients aren't charged for unnecessary procedures. Essentially, prior auths were meant to deter healthcare fraud. However, there isn't one statistic that shows increases in prior authorizations can decrease medical fraud. In fact, one could argue that prior authorizations are linked to insurance fraud and caused by the very corporations tasked as the watchdogs. e facts are simple, yet the situation continues to deteriorate our nation's healthcare: prior authorizations don't decrease the cost of healthcare or improve it. We know this because the cost of healthcare continues to rise, and patients are suffering needlessly due to delayed access to treatment. e thin line between profit and loss is a national concern for America's healthcare facilities; meanwhile, the health insurance industry's billions in revenue are generated from our struggle. In the larger landscape, while patients advocate for their rights in the courts, payers might start acknowledging that approving patient procedures could potentially cost them less than the financial burden of facing and losing multiple lawsuits. In the meantime, as we wait for the CMS Prior Authorization Rule to play out in the years ahead, nimble is closely monitoring initiatives aimed to streamline the prior authorization process, including UnitedHealthcare's national Gold Card Program. is initiative is slated for 2024 implementation across UnitedHealthcare's commercial, Medicare Advantage, and Medicaid platforms to pre- approve qualified members for most procedure codes. We're curious to see if other carriers adopt similar programs, as well as the percentage of beneficiaries deemed eligible (and what the eligibility requirements are), and we'll continue to adjust our strategy and inform you of our progress. In the pursuit of a more efficient and patient-centered healthcare system, nimble stands at the forefront, ready to meet the evolving needs of our clients to meet payer challenges head-on. -- Visit nimble solutions during Becker's 29th Spine, Orthopedic and Pain Management-Driven ASC + e Future of Spine Conference on June 19 – 22, 2024 in Chicago for additional revenue cycle management solutions. Go to nimblercm.com to learn more.

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