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Implementation of RPA Solution for Prior Authorization Automation in Healthcare Revenue Cycle

enterbridge.com

Medical

Healthcare

Revenue Cycle Management

Challenges in Manual Prior Authorization Process

The organization faced critical staffing shortages and operational inefficiencies due to manual prior authorization (PA) workflows. Staff spent excessive time on repetitive tasks including dual-system navigation, data entry errors, and lack of process scalability, leading to revenue cycle bottlenecks and delayed patient care.

About the Client

Healthcare organization seeking to optimize revenue cycle operations through automation

Automation Goals for Revenue Cycle Optimization

Reduce prior authorization processing time by 90% through RPA implementation
Eliminate 90% of manual staff intervention in PA workflows
Reallocate staff resources to higher-value revenue cycle tasks
Ensure 100% data accuracy in PA submissions
Establish scalable automation framework for future expansion

Core Automation System Requirements

Automated EHR and payer portal authentication
Cross-system data extraction and validation (HCPCS/ICD10 codes)
Intelligent PA requirement determination
Automated submission workflow with exception handling
Audit trail creation in source systems
Real-time status tracking dashboard

Technology Stack Preferences

Robotic Process Automation (RPA)

Optical Character Recognition (OCR)

API Integration Frameworks

System Integration Requirements

Electronic Health Record (EHR) systems (e.g., Epic, Cerner)
Payer portals (BCBS, UnitedHealthcare, Aetna)
Revenue cycle management platforms
Active Directory authentication

Operational Requirements

24/7 system availability with failover capabilities
HIPAA-compliant data handling
Sub-second response times for transaction processing
Scalable architecture for 10x volume growth
Role-based access control (RBAC)

Expected Business Outcomes

Implementation of RPA automation is projected to reduce prior authorization workload by 90%, freeing clinical staff for direct patient care activities. The organization should expect improved revenue cycle velocity through faster PA completion, reduced operational costs, and enhanced compliance through automated audit trails. System scalability will support future automation of related revenue cycle workflows.