Prior Authorization Automation for a Regional Health System
The Challenge
A regional health system with multiple hospitals and outpatient clinics was processing prior authorization requests manually. Clinical staff spent an estimated 18 to 22 hours per week per site on PA submissions, status checks, and appeals. Denials were rising due to incomplete submissions, and delays in authorization were affecting patient scheduling and satisfaction scores.
Our Approach
We began with a six-week discovery and requirements phase to map every PA workflow variant across payer types and procedure categories. We designed a HIPAA-aligned agent architecture that integrated with the existing EHR via approved APIs. Safety requirements included mandatory human review for any PA requiring clinical judgment and complete audit logging of every AI-generated output.
The agent was built to draft PA submissions, attach supporting documentation from the patient record, check submission completeness before filing, and flag likely denial risk based on payer-specific criteria. Human staff reviewed and approved every submission, the agent handled documentation and routing, not clinical decision-making.
What We Built
- PA drafting agent integrated with EHR and payer portals
- Document completeness validator with pre-submission checks
- Denial risk scorer based on payer-specific criteria
- Human approval workflow with single-click review interface
- Complete audit log for every AI-generated action
- HIPAA compliance documentation for the AI system
Outcomes
Key Lesson
The most impactful improvements came from completeness validation, catching missing documents before submission, not after denial. The agent's value was in eliminating rework, not replacing clinical staff.