Edifecs and VirtualHealth Partner to Automate Prior Authorization for Payers and Providers, Comply with Future Federal and State Mandates

Leveraging AI and NLP from recent acquisitions and FHIR standards, Edifecs and VirtualHealth provide automated prior authorization in real-time

Edifecs, a global health information technology solutions company and VirtualHealth, an industry-leading medical management technology company, today announced a partnership to provide automated prior authorization to VirtualHealth’s HELIOS platform for healthcare payer and provider clients.

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“This enabled our team to build an intelligent automated solution that significantly reduces the burden of prior auth, expediting patient care and reducing the drain on cost and resources for payers and providers alike.”

The Edifecs solution will automate and optimize the prior authorization process across HELIOS to significantly reduce the administrative burden, alleviate friction between payers and providers, and ultimately expedite patient care. According to WEDI, automating prior authorization could save the medical industry $25 billion. Based on client feedback, VirtualHealth is adding Edifecs’ prior authorization solution to streamline prior authorizations for their commercial health plan, ACO, home health, and healthcare system clients.

HELIOS is the first cloud-native medical management platform, purpose built to support value-based, whole-person care. Its innovative architecture of utilization management (UM) and complex care management (CM) within a single ecosystem maximizes collaboration, coordination, and care delivery for the entire care team. HELIOS’s configurable design and unique approach helps eliminate data silos, simplifying UM and CM processes and reducing the need for IT resources.

“The prior authorization process is a tremendous burden across our healthcare system impacting both payers and clinicians. For more than two decades we have helped eliminate friction between payers and providers, giving us deep insight into their workflows, data sets, and business and administrative processes,” said Venkat Kavarthapu, CEO, Edifecs. “This enabled our team to build an intelligent automated solution that significantly reduces the burden of prior auth, expediting patient care and reducing the drain on cost and resources for payers and providers alike.”

“Prior authorization has been a burdensome issue across the industry and is a pain point we hear about from many of our clients,” said Adam Sabloff, Founder and CEO of VirtualHealth. “Offering a streamlined prior auth process will help HELIOS users improve patient care experiences and outcomes, and to transform the healthcare system for the betterment of all. We’re very pleased to be able to partner with Edifecs to bring their electronic prior auth solution to HELIOS users.”

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Edifecs’ automated prior authorization solution is built on its proven interoperability platform used by hundreds of customers, processing healthcare data for more than 290 million people. It leverages artificial intelligence, natural language processing, and industry standards such as FHIR^® to instantly deliver authorizations. The solution streamlines payer and provider collaboration with automated electronic health record (EHR) integration and data retrieval to reduce the resource burden, and increase efficiencies and cost savings. Edifecs’ prior authorization solution complies with existing state, federal, and all Centers for Medicare & Medicaid Services prior authorization regulations and will automatically adhere to future regulations.

The Centers for Medicare & Medicaid Services recently issued a proposed rule to reduce the burden prior authorization places on payers, providers, and patients. Additionally, the industry expects the majority of states are planning prior authorization regulation in 2023.

The Edifecs prior authorization solution provides real-time adjudication resulting in more b******, fewer claim denials, and faster reimbursement. Additionally, it significantly decreases the administrative burden on providers allowing them to focus more time on patient care and alleviate physician burnout.

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