Paying the Price When Provider Data is Unclear

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In 2018, 57% of Americans experienced a surprise medical bill — that is, an invoice for services they thought were covered by insurance¹. Of that group, 20% reported that these unexpected bills were the result of visiting a doctor who was not part of their insurance network.

To find an in-network practitioner, and his or her office location, hours and contact information, many consumers rely on their health plan’s provider directory. …

Streamlining this process will save time, money and improve patient access to care.

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Prior authorization is intended to help manage the use of healthcare resources, reduce overuse or misuse of services and control healthcare spending.

At a high level, the process is seemingly straight-forward: a healthcare provider will submit their intended treatment plan to the patient’s insurance, the plan will review the request, ask for follow-up information if necessary and issue a decision as to whether or not it is authorized.

A standard electronic method for conducting at least a portion of the prior authorization process has been federally mandated since the early 2000s. However, nearly 20 years later, 88% of prior authorizations are still conducted either partially or entirely manually,¹ using faxes and phone calls to request and provide clinical information. …

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There is a lot of buzz around artificial intelligence (AI) right now.

Millions of people rely on AI-powered voice assistants like Alexa and Siri as a normal part of life. Everyone is familiar with Netflix and other streaming video services suggesting what to watch next. Google auto-filling online forms is a great time-saver, albeit a nuisance at times. AI is no longer science fiction — it’s mainstream.

Just about every industry has been employing AI technology to create efficiencies and improve quality for decades. …



CAQH, a non-profit alliance, is the leader in creating shared initiatives to streamline the business of healthcare.

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