True Automation in Healthcare Decision-Making Is Happening, Just Not As Fast As You Wish

The following is a guest blog post by Keith J. Saunders, Esq., Founder & CEO of FHAS.

FHAS has adjudicated over 1.7 million complex medical claims, appeals, peer reviews, administrative disputes, and audit reports over the last 22 years. With a small army of physicians, attorneys, nurses, and administrative professionals, we analyze results, make timely decisions, and determine root causes. Along the way, multiple technologies have attempted to expedite and automate this process. Trial and error determined that none were a perfect fit for us, so we decided to create our own.

FHAS started with the simple goal of automating complex medical-decision making for insurance carriers, third-party administrators, and healthcare providers. However, we ended up with a SAAS platform furnishing a suite of services based upon client needs. Cogno-Solve receives large, complex medical files in PDF form, sorts through massive data sets to find the pertinent information, and then applies coverage guidelines to determine whether the coverage should be approved or denied. Cogno-Solve then drafts a decision for a healthcare professional’s review, and the professional makes the final determination.

This process took years, and the assumed easy parts were the hard parts. Like most companies, we employed design-thinking methodologies, spent an inordinate amount of time talking to our customers about their challenges, and developed prototypes. As customer needs changed, solutions adapted accordingly. Our development team utilized agile methodology, although they frequently felt a new song was constantly getting played by the DJ, which required them to start a new programming dance. Timeline implementations became ranges instead of hard dates due to variables that arose during the process. Most importantly, each proposed solution required the customer to update several other aspects of their business workflow. From digitization of files to enhancing their data-extraction process, client systems needed upgrades that we didn’t anticipate at the onset to make medical decision-making a reality.

While no part of it was easy, we ultimately saw our entire decision-making process accelerate. Our staff now spends 30% less time reviewing forms and sorting through data, and instead reviews ready-made solutions and then applies any individual considerations to the case decision prior to issuance.

Our story isn’t unique. The healthcare industry is demanding a more efficient decision making process. Many health plans are using some form of rule-based decision-making automation to handle claims review. On the provider side, many health systems utilize some type of pre-adjudication in which certain data points can be plugged in to determine in advance whether payment will happen. With robotic process automation (RPA) handling these administrative processes, such as uploading files, extracting data, and populating forms and databases, organizations are able to focus their attention on quality of care. While this process is slow, particularly as security and PHI/PII understandably eat up much of a company’s IT budget, automation is happening and is making a positive impact.

To summarize, we learned that there is never a straight line from problem to solution. Successful implementation of new technology, especially one surrounded by as much controversy as automation, depends more on the organization’s willingness to make a change than anything else. Changing hearts and minds is far more difficult than the deployment itself. An intended technology fix requires several foundational fixes at the workflow level to realize change.

About FHAS
FHAS, a URAC accredited IRO and ISO 9001 certified company, is one of the largest independent providers of “healthcare as a service” (HAAS) for government and commercial clients with a particular focus on adjudication services and medical claims’ review services. In 1996, FHAS began furnishing Medicare Fair Hearing Services to Durable Medical Equipment (DME) Administrative contractors located throughout the United States. Since that time, FHAS has expanded its scope of appeals services to include complex medical reviews for the following: Medicare Parts A, B, PDRC Appeals, and DME Appeals, internal and external health plan appeals, and the entire Pennsylvania Medicaid fair hearing process. FHAS utilizes a network of board certified physicians, legal professionals, and other healthcare professionals with diverse specialties, who have the expertise to render decisions for external review requests. In addition to professional services, FHAS provides enterprise-grade software solutions to healthcare and insurance industries. Their newest product Cogno-Solve is a comprehensive, RPA software platform that automates claims and appeals decision-making functions.