UHC was sued last November for (allegedly) using AI to process prior authorizations for MA plans (case notes: https://bit.ly/3VFWXzR). 90% of prior authorization denials were reversed upon appeal, which insinuates that they were incorrect in the first place. This issue is the reason we started Protego Health. In a world where health plans use technology to process and deny claims, there is no punishment for incorrectly denying care, and providers are using people to solve an issue caused by machines, patients and providers will inevitably be left holding the bag.

There are some great softwares that integrate into clinical workflows in an effort to prevent downstream denials. But 60-90% of denials, both prior-auth denials and post-service, are overturned. So what we are left to conclude is that you can do everything right and still get denied, and then what? Denials go up every year, and are consistently rated the most time consuming and expensive part of Revenue Cycle Management. Curious what providers have been doing to combat this - are you building internal tools, seeking software solutions in the market, or trying to combat this through relationship building with your payers? Some combination?

‍