Clarifying Post Acute Analytics’ Role in Prior Authorization and AI Use
Background
On May 17, 2023 the U.S. Senate Permanent Subcommittee on Investigations (PSI) launched an inquiry into the barriers facing seniors enrolled in Medicare Advantage programs who were seeking post-acute care, particularly skilled nursing care following an investigative reporting series from STAT+ into naviHealth (now Optum Home and Community). The reporting scope expanded to include AI algorithms that “deny care” for post-acute services. Specifically, the subcommittee focused on prior authorization denials for post-acute services from United, Humana, and CVS/Aetna between the years 2019-2022. A report on the finding of the subcommittee was released to the public on October 17, 2024.
Internal documents from CVS/Aetna during this time period do mention Post Acute Analytics (PAA). The subcommittee has mistakenly attributed increased prior authorization denials for skilled nursing facility (SNF) requests from CVS/Aetna to the use of Anna software. To be clear, PAA software or workflows were never utilized by CVS/Aetna to make any prior authorization recommendations. Further, PAA never utilizes artificial intelligence (AI) to deny skilled nursing facility (SNF) requests. However, we welcome this opportunity to address these concerns and provide clarity on our processes.
Our Commitment to Facilitating Care
At Post Acute Analytics, our primary mission is to support healthcare providers and patients by streamlining the prior authorization process for post-acute care services. We aim to ensure that patients receive timely access to the care they need without unnecessary delays and surprise denials of service.
Role of AI in Our Processes
Our AI-driven platform is designed to enhance efficiency and accuracy in the prior authorization process by:
- Accelerating Approvals: AI helps quickly identify requests that meet widely accepted and publicly available clinical guidelines, allowing for faster approvals.
- Reducing Administrative Burden: By automating routine tasks, we enable clinicians to focus more on challenging requests that may require specialized review rather than routine administrative processes.
- Enhancing Compliance: The technology ensures that all approvals align with current clinical standards and regulatory requirements and are audited internally and can also be audited by our client clinical teams.
We Focus on Approvals, Not Denials
The Anna software platform and PAA supported clinical workflows have the following characteristics that were not mentioned in the congressional report:
- Approval-Oriented: Our AI tools are utilized exclusively to expedite approvals. They assist in identifying cases that clearly meet clinical criteria so that patients can receive care promptly.
- Human Oversight on Denials: Any requests that are not immediately approved by the AI system (due to lack of documentation for example) are referred to qualified clinical professionals for thorough review. Denial decisions are never made by AI algorithms but by experienced human clinicians.
- Collaborative Process: We work closely with providers to gather any additional information needed to support an approval, prioritizing patient access to necessary services.
Ensuring Ethical and Responsible Use of AI
PAA is committed to the ethical use of AI in healthcare:
- Transparency: We maintain open communication about how our technology is used in the prior authorization process.
- Patient-Centered Approach: All decisions are made with the patient’s best interest in mind, guided by evidence-based clinical criteria.
- Regulatory Compliance: Our processes comply with all applicable laws and regulations, including those related to patient rights and data privacy.
Post Acute Analytics is dedicated to improving the healthcare system by ensuring that patients receive the post-acute care they need in a timely and efficient manner. Our AI technology is a tool to support this goal by streamlining approvals and reducing administrative hurdles.