Case Study | Healthcare Payer

Clinical Decision Support System

Empowering healthcare providers to deliver more timely and effective patient care through a prior authorization system with an enhanced clinical decision engine.

Overview

A specialty health insurance company wanted to optimize their prior authorization (PA) process and outdated decision-making platform. 10Pearls designed and developed a sophisticated decisioning engine and automated key workflows to enhance the legacy system and streamline the entire PA lifecycle.

Reduced PA decisioning process
from months to weeks

Reduced platform ownership costs
by 5x with an in-house system

Challenge

The legacy system and complicated prior authorization (PA) process led to inconsistent decision-making and delays. The inability to efficiently manage PA evaluations was straining resources, while limited scalability for configurable workflows effected the ability to adapt to growing demands. These inefficiencies ultimately restricted the delivery of timely and effective care, compromising both operational efficiency and patient outcomes.

Solution

10Pearls leveraged Appian, a leading process automation platform, to build a comprehensive in-house decisioning system, featuring updated and advanced rulesets. Key prior authorization (PA) processes were automated, significantly reducing manual workload for clinicians. Through extensive research and user interviews, we designed an intuitive interface that improved usability for both clinical and administrative teams. Integrated configuration management tools enabled seamless system customization without the need for IT support. This solution enhanced PA decisioning accuracy and accelerated authorization times, resulting in enhanced accuracy, improved patient access to necessary treatments, and streamlined operations.

Customer

Leading national healthcare provider

Services

Tech Stack

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