Salesforce (CRM) and Blue Shield of California have partnered to create an artificial intelligence-based system that should, they contend, make it easier for patients to get approval for care through their insurer—and reduce the burden of prior authorizations from weeks-long delays to, ideally, a same-day process.
The collaboration is expected to be announced this morning.
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The idea isn't new, as some major insurers have engaged in the use of AI to address claims approvals or denials in the past — and are now facing significant blowback amid concerns about increased denials, especially for older patients.
Prior authorizations are decision processes insurers use to determine if a treatment, procedure, drug, or other medical service is medically necessary for the patient based on the insurer's coverage policies.
The claim is typically reviewed by a medical expert on the insurer's team. The process is designed to ensure that prior steps have been taken into account — like an imaging scan before a surgery — or that other less expensive or less serious options have been tried before approving the request.
Blue Shield isn't leaving the process up to AI exclusively, but instead will continue using its team of clinicians as part of the process — which means some claims might still take some time.
Blue Shield CEO Paul Markovich told Yahoo Finance in an exclusive interview that the new system, based on Salesforce's healthcare cloud system, aims to avoid the pitfalls faced by other insurers relying on AI.
"At no point are we going to be denying care without a human being in the loop and having the availability for the clinician to speak to a qualified counterpart," Markovich said.
This, he said, means that there won't be a need to face complaints of increased denials, seen by other insurers.
"We don't see that being an issue in terms of any kind of machine-driven process denying care," he said.
Instead, Markovich likened the process to credit card use. There is a prior authorization process too, but many users today don't realize it since the card taps or swipes are approved within seconds. And if something goes wrong or fraud is detected, the company notifies the customer and blocks the charge.
But it's the approval part that the AI will help with, to help reduce time for cases that match the policies and should be easy to greenlight.
Will AI approve surgical procedures in a more timely way? (Getty Creative) ·skaman306 via Getty Images
The software will work by utilizing the existing coverage policies and overlaying a patient's electronic health data to ensure all the boxes are checked before approval is given. For example, if a patient needs a surgery, the system will check that other treatment options and necessary imaging have been done before approving the surgery and that the surgery is appropriate for the disease or condition.
Electronic health records are key to the puzzle and a reason why the new system can be so easily deployed in California, where state laws require health information to be easily available. It will be harder to emulate in other states that are still reliant on fax machines to transfer health records or request prior authorization approvals.
Markovich hopes that as the new process begins to roll out with health systems throughout 2025, it will help end the need for faxes, which help link care for patients who use different healthcare providers with different data-keeping systems.
"We expect to be eliminating, or at least semi-retiring, fax machines," he said.
Jeff Amann, an executive vice president and general manager of Salesforce Industries, told Yahoo Finance that Blue Shield and Salesforce co-created the system. It began when Salesforce noticed that there are up to 13 different authorized sources — like hospitals, doctors' offices, behavioral health specialists, etc. — that keep records for a single patient.
What normally happens is that care managers "swivel chair" among those disparate systems and information within those systems, then send faxes around to try to get approval.
"It's this kind of bird's nest of communications, and it consumes a lot of time," Amann said.
Salesforce found out the process can take a week or as long as 30 days for a clinician to get approval for a patient's care needs. Amann said the idea is now to launch a process that can go through the same steps in "near real-time."
"I think that's where the world probably should have been a long time ago, and sometimes I'm surprised that it's taken the industry this long, but I'm really glad to be a part of that," Amann said.
Salesforce can now sell the same services to other insurers, and Amann claimed there are a number already working with the company to launch a similar system overhaul.
"So Blue Shield is first, they're not, at this point, even the only ones. It's very rapidly getting uptake in the market," Amann said. He declined to provide specific names.
Blue Shield's Markovich has been critical of his own industry, calling for greater transparency and efficient use of technology over the years. This, he said, is another example of trying to make it happen and encourage his peers to follow suit.
"I just think it's going to be table stakes to do it this way. And we're all going to have to do it in a way ... where there's always a human in the loop. I don't think you can continue to say that the black box machine said no. It won't work," he said.
Anjalee Khemlani is the senior health reporter at Yahoo Finance, covering all things pharma, insurance, care services, digital health, PBMs, and health policy and politics. That includes GLP-1s, of course. Follow Anjalee on most social media platforms @AnjKhem.
