METHODS, SYSTEMS, AND COMPUTER PROGRAM PRODUCTS FOR PREDICTING WHEN PRIOR AUTHORIZATION IS REQUIRED FOR A HEALTH CARE PROCEDURE USING STATISTICAL ANALYTICS

Abstract: a method includes processing, by one or more processors, historical claim and claim remittance information to extract prior authorization data; performing, by the one or more processors, a probabilistic analysis on the prior authorization data for a procedure to generate a first metric and a second metric, the first metric comprising a percentage of claims including the procedure in which prior authorization is applied for and the second metric comprising a percentage of claims including the procedure in which prior authorization was not applied for and were denied payment for not applying for prior authorization; determining, by the one or more processors, whether the first metric satisfies a first authorization threshold and the second metric satisfies a second authorization threshold, the first and second thresholds being associated with a prior authorization rule corresponding to the procedure; and generating, by the one or more processors, a recommendation on whether to obtain prior authorization before performing the procedure based on whether the first metric satisfies the first authorization threshold and the second metric satisfies the second authorization threshold.

Inventor(s): Ting-Yu Ho, Guohua M. Zhao, Letitia Murr, Feili Yu, Michael F. Neale, John D. Evans, Mark J. Fleming

CPC Classification: G06Q20/405 ({Establishing or using transaction specific rules})

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