success story

Transforming Prior Authorization Process at a Nonprofit Managed Care Facility

The Healthcare industry is one of the fastest growing industries in today's economy, absorbing more than 10% of the gross domestic product of most developed nations. Due to individuals and healthcare organizations paying greater attention to health-related issues, there has been a significant increase in the number of patients visiting hospitals and health clinics across the world. Most healthcare maintenance organizations must process innumerable documents for coverage approvals, as well as follow up with patients at various stages of the approval process to provide timely healthcare coverage.

In the entire payer-provider-patient cycle of the healthcare market, when a provider or a physician recommends medical care or a procedure for a patient, prior authorization plays a vital role. It helps to streamline the healthcare service and prevents delays in providing the right medical care to patients. Having a sophisticated prior authorization process is crucial for the payer and provider.



The Challenge

A paper-based, manual-effort intensive, unreliable and inefficient pre-authorization process

Providers must obtain prior authorizations for certain medical services before they can perform these services. The client was using inefficient data models to solve business problems, and because of this, they were facing major issues in their pre-approval workflow. These issues included a paper-based pre-authorization process and a need for manual data entry. The approval process was highly burdensome, unreliable, and inefficient. They were confronted with many challenges, including:

  • Improving the process for submitting request forms
  • Bolstering the request forms with sufficient and accurate information
  • Handling high volumes of service requests in a timely manner
  • Ensuring low costs and high-quality patient care

The issues causing these challenges were resulting in a poor customer experience because the end-users had to go through a long, burdensome process before they could receive the care they needed.

The Solution

End-to-end digital transformation of the pre-authorization process, based on process orchestration, case life-cycle management, business rules and automation

Virtusa utilized Savvion 7.6.1 BPM Suite and data provided by Savvion Actional to automate and optimize the prior authorization process. The improved process features:

  • Unique authorization forms (fifteen unique forms including ten new procedures) for providers or other system users to raise authorization requests
  • Business rules to help the decision-making process of automatically approving, denying or pending an authorization request, enabling straight through requests processing
  • Business logic for prioritizing requests and allocation of requests to the system users ensuring that requests are handled on a priority basis
  • Implementing SLA and alerts to help reduce cycle times involved in request processing
  • Reports on status, escalation, medical denial, nurse productivity, and a list of unassigned tasks, as well as dashboards that display this information for providers, assistants, nurses, and medical directors
The Solution
The Benefit

40% reduction in processing time of customer requests and administrative costs

Virtusa helped:

  • Reduce manual intervention by using straight through requests processing and decreased operating costs by automating the authorization process
  • Improve patient and provider service by reducing the cycle time of requests processing by 40%
  • Improve visibility of the entire business process through reporting and dashboard capabilities, enabling identification of non-compliance trends
  • Reduce administrative costs by 40% in the first year of deployment by automating business processes
Related content