Salesforce (CRM) and Blue Shield of California have partnered to build an artificial intelligence-based system. They argue that this should make it easier for patients to get treatment approved through their insurance company, reducing the burden of weeks of prior authorization. Ideally late to same day process.
The collaboration is expected to be announced this morning.
The idea is not new, as some major insurance companies have worked on using AI to address claim approval or denial in the past. And now it faces significant headwinds amid concerns about increased denials, especially to older patients.
Prior authorization is a decision-making process that insurance companies use to determine whether a treatment, procedure, drug, or other medical service is medically necessary for a patient based on the insurance company's coverage policy.
Claims are typically reviewed by medical professionals on the insurance company's team. This process ensures that prior steps, such as pre-surgical imaging scans, have been considered, or that other cheaper or less severe options have been tried, before approving the request. It is designed to.
Rather than leaving the process solely to AI, Blue Shield instead plans to continue using its team of clinicians as part of the process. This means some claims may still take some time.
Blue Shield CEO Paul Markovich said in an exclusive interview with Yahoo Finance that the new system, based on Salesforce's healthcare cloud system, avoids the pitfalls faced by other insurance companies that rely on AI. He said it was aimed at.
“At no point do we deny treatment for conditions that do not involve a human being and the clinician does not have the opportunity to speak to a qualified representative,” Markovich said.
This means they won't have to face complaints about increased denials as seen from other insurance companies, he said.
“In terms of any kind of machine-driven process denying care, I don't think that's the issue,” he said.
Instead, Markovich likened the process to using a credit card. There is also a pre-approval process, but many users today are unaware of it because a tap or swipe of a card is approved within seconds. Also, if something goes wrong or fraud is detected, the company will notify the customer and block the charge.
However, it is in the approval part that AI will help with, which should speed up the time and ease of approval for cases that match policy.
The software works by leveraging existing coverage policies and overlaying the patient's electronic health data to ensure all boxes are checked before approval is granted. For example, if a patient requires surgery, the system verifies that other treatment options and necessary imaging have been performed and that the surgery is appropriate for the disease or condition before approving the surgery.
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Electronic health records are the key to the puzzle and the reason the new system is so easy to implement in California, where state law requires health information to be readily available. It would be difficult to replicate in other states that still rely on fax for medical record transfers and prior authorization requests.
Markovic expects health systems to begin rolling out new processes throughout 2025, eliminating the need for fax machines. Fax could help link care for patients with different healthcare providers and different data retention systems.
“We anticipate that fax machines will be phased out, or at least semi-phased out,” he said.
Jeff Amann, executive vice president and general manager of Salesforce Industries, told Yahoo Finance that Blue Shield and Salesforce co-developed the system. This started when Salesforce realized that up to 13 different accredited sources, including hospitals, clinics, and behavioral health professionals, were storing a single patient's records.
What typically happens is that the care manager acts as a “swivel chair” between those different systems and the information within those systems and sends faxes to get approvals.
“It's a bird's nest of communication, and it consumes a lot of time,” Amann said.
Salesforce has found that the process for a clinician to get approval for a patient's care needs can take up to a week and up to 30 days. Amann said the idea is to launch a process that can perform the same steps in “near real time.”
“I think the world probably should have been there a long time ago. I'm sometimes surprised that the industry has taken this long, but I'm really happy to be a part of it,” Aman said. said.
Salesforce can now sell the same service to other insurance companies, and Aman claimed that many insurance companies are already working with the company to undertake similar system overhauls.
“So Blue Shield is the first, but it's not the only one right now. It's penetrating the market very quickly,” Amann said. He declined to provide specific names.
Blue Shield's Markovich has long been a critic of his industry, calling for greater transparency and efficient use of technology. This is another example of him trying to do that and encourage his colleagues to follow suit, he said.
“I think it's going to be a high-stakes gamble to do it this way, and we're all going to need to do it in a way that always involves humans. I don't think we can continue.'' The black box machine said no. ” he said.
Anjalee Khemlani is a senior health reporter at Yahoo Finance, covering all areas of pharma, insurance, care services, digital health, PBM, and health policy and politics. Of course, this also includes GLP-1. Follow Anjalee on most social media platforms @AnjKhem.
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