Blue Cross Blue Shield of Massachusetts Uses Artificial Intelligence to Speed Review Time, Automate Authorizations & Eliminate Administrative Costs

By October 12, 2022 November 12th, 2022 News

BOSTON — Blue Cross Blue Shield of Massachusetts (“Blue Cross”) today announced the completion of a proof-of-concept pilot called “FastPass,” an automated prior authorization process from end-to-end, eliminating the need for faxes, phone calls and manual processes for payers and providers. The initiative, piloted at New England Baptist Hospital (NEBH), focused on addressing the major problem areas, including reducing the time from submission to decision, alleviating administrative burden, decreasing clinical review time, and increasing clinician satisfaction.

The Problem
Prior Authorization (also known as “Pre-Certification”) is a process through which a clinician seeks advanced approval from a health plan to ensure that a service or treatment is covered, medically necessary, and not duplicated. Prior authorizations exist to manage excess health care costs and mitigate patient risk while also helping ensure consumers receive high-quality care. However, prior authorization can be cumbersome for clinicians.

“We realize that the prior authorization process is widely recognized as the single biggest administrative pain point for hospital staff,” said Kathy Gardner, RN, vice president of clinical operations at Blue Cross. “We wanted to figure out a way to retain the value of prior authorizations – ensuring our members receive treatments that are medically necessary and clinically effective – while eliminating the administrative burden on our clinical partners and allowing members to get the care they need sooner.”

How it works
Blue Cross engaged Olive, a leading automation and intelligence company bridging the divide in health care, to help streamline both clinician and payer processes and prior authorization decision-making using artificial intelligence (AI).

The technology automated the process of cross-checking Blue Cross’ prior authorization requirements in real-time to identify if a prior authorization was required. If a prior authorization was not required, the provider received instant notification that they could proceed with scheduling the procedure. When prior authorizations were required, FastPass used AI to cross-check the clinical history in the electronic medical record against Blue Cross’ medical necessity criteria and automatically generate a recommendation in real time, again giving the clinician the ability to proceed with scheduling the procedure. For the remaining prior authorization submissions that required more complex clinical review, FastPass automatically packaged and made available all the clinical documentation and notes to the clinical review team, significantly streamlining and accelerating the reviews.

The Results
The pilot at NEBH focused on hip and knee procedures for 32 orthopedic providers over the course of a four-month period. 88% of prior authorization submissions were processed automatically in real-time. The overall impact on prior authorization approval time went from an average of nine days to an average of less than one day. The associated impact on administrative burden and cost has been significant for Blue Cross.

“The FastPass proof-of-concept is just one step in our journey toward automating prior authorizations across BCBSMA to continue to make the process frictionless for our clinical partners and ultimately our members,” said Deb Vona, senior director of business operations at Blue Cross.