BACKGROUND

Most, if not all, payers of health insurance benefits have rules requiring beneficiaries of a health insurance plan to obtain preauthorization for certain medical services. For example, the payer may require preauthorization for medical services that are deemed expensive, experimental, and/or routinely unnecessary. If preauthorization in not obtained, the payer is not obligated to pay for the medical service. The rules and procedures for obtaining preauthorization are different for each payer and may vary between the different insurance plans offered by a single payer.

Obtaining preauthorization is generally too complicated or burdensome for the patient. Accordingly, health care providers shoulder the responsibility of learning the unique rules and procedures relating to preauthorization for each health insurance plan offered by each payer with whom the health care provider works. All too often, the rules about what medical services require preauthorization and/or the procedures for obtaining preauthorization are not well-documented or readily available to the insured or the health care provider and may change without notice.

The problems associated with preauthorizations faced by health care providers include difficulty in identifying medical services that require preauthorization for different plans and payers, procedural issues relating to submitting requests for preauthorization, and keeping track of pending requests to ensure that preauthorization is obtained. Dealing with these problems adds administrative overhead in the form of additional staff, special procedures, and/or ongoing training, all of which increases expenses of the health care provider. An estimated $31 billion per year is spent dealing with prior authorizations. The consequences of mistakes when preauthorization is required include, for example, claim payments being delayed to claims being denied and unpaid. It is with respect to these and other considerations that the present invention has been made.

BRIEF SUMMARY

Various embodiments of a preauthorization management system allow a health care provider to submit a preauthorization request and track the status of the preauthorization request until a final determination is reached. Once a preauthorization request has been submitted, the preauthorization management system monitors the status of the request until a final disposition is reached. The preauthorization management system documents the submission and determination process to provide a record that may be used to show an event or outcome occurred.

Embodiments of the preauthorization management system include a preauthorization request engine running on a computing device. The preauthorization request engine is in communication with one or more databases including, but not limited to, a payer database, a request database, and a work queue database. Some embodiments of the preauthorization management system include an internal web server running an intermediary web service that accepts web service calls from the preauthorization management engine. When a web service call from the preauthorization management engine is received, the intermediary web service accesses the web content from the payer system and displays it in a web portal viewable through the user agent. In various embodiments, the web content from the payer system is displayed along with supplemental web content provided by the preauthorization management system that offers additional information and/or guidance to the user.

The preauthorization management method executed by the preauthorization management system begins after the preauthorization management system receives an order entered by the health care provider that includes a medical service requiring preauthorization. The preauthorization management system may automatically initiate the preauthorization request submission process for orders requiring preauthorization. Alternatively, the preauthorization request submission process may be manually initiated by the user. The preauthorization management system determines whether the payer system provides electronic status information (e.g., online) or inquiries must be made manually (e.g., by telephone or fax). If the payer system provides electronic status information, the preauthorization management system contacts the payer system to determine if a preauthorization request has been previously submitted to avoid making a duplicate preauthorization request for the patient and the medical service.

If a preauthorization request for the patient and the medical service is not pending, the preauthorization management system determines whether the payer system accepts electronic submissions or submissions must be made manually. If the payer system accepts electronic submissions, the preauthorization management system attempts to automatically submit the preauthorization request to the payer system.

In various embodiments, the preauthorization management system extracts and evaluates the information in the response from the payer system, updates the authorization record associated with the preauthorization request based on the information in the response from the payer system. In various embodiments, the preauthorization management system moves the preauthorization request to the appropriate work queue based on the response from the payer system. The preauthorization management system may also maintain work queues for scheduling automatic status inquiries, which may or may not be directly visible to or accessible by the user in the same manner as other work queues.

Embodiments of the preauthorization management system determine which pending preauthorization requests qualify for automatic inquiries and automatically perform a periodic status inquiry on a selected schedule until a final determination is reached. Because the availability of electronic status inquiry systems may change from time-to-time, the auto-inquiry evaluation operation is a recurring operation.

