Edifecs Launches Solution to Automate Prior Authorization at the Point of Care


Leveraging AI and NLP from recent acquisitions and FHIR® standards, Edifecs solves the prior authorization challenge for payers and providers

Edifecs, has a new solution to automate prior authorization at the point of care, leading to improved member experiences, enhanced outcomes, ongoing compliance and reduced administrative burden. Edifecs’ automated prior authorization solution integrates with electronic health records (EHR) and leverages artificial intelligence (AI), natural language processing (NLP), and industry standards such as FHIR to drive nearly immediate authorizations.

With its recent acquisition of Talix and Health Fidelity, Edifecs expanded its risk adjustment business, AI technology, and EHR integration capabilities and is uniquely positioned to transform the prior authorization process. Edifecs’ solution streamlines payer and provider collaboration with automated EHR integration and data retrieval for increased efficiencies and cost savings. Edifecs prior authorization complies with existing state, federal, and all Centers for Medicare & Medicaid Services prior authorization regulations and will automatically adhere to future regulations.

“Prior authorization is one of the biggest challenges providers face today causing tension and abrasion between providers and payers,” said Venkat Kavarthapu, CEO of Edifecs. “Additionally, when patients are forced to postpone medical procedures to wait for insurance approval, the repercussions on patients’ health can be irreversible. We’re thrilled to introduce a next-generation solution that streamlines this process to ensure patients get the care they need when they need it.”

The solution delivers full payer prior authorization management workflow with tracking, monitoring, and reporting and integrates with the existing utilization management systems. Edifecs prior authorization technology also connects to the payer’s clinical guideline repository. By leveraging industry standards like FHIR and over 40 payer implementations for patient access, Edifecs’ prior authorization solution significantly reduces the time to care through EHR-agnostic integration with providers.

“Payers face complex challenges processing prior authorization requests. Our purpose-built solution is designed to ease provider friction and simplify the process with automated, agnostic EHR integration, data retrieval, and built-in regulatory compliance,” continued Kavarthapu.

According to the Medical Group Management Association, prior authorization is the largest administrative burden on providers. The Council for Affordable Quality Healthcare Index reports the cost to manually process prior authorization for providers increased over 60% from $6.61 in 2018 to $10.92 in 2019. Prior authorization also continues to garner national attention as a result of the introduction of the bipartisan, bicameral, “Improving Seniors’ Timely Access to Care Act” (H.R. 8487) aimed at simplifying the prior authorization process.