Microsoft Scenario Library Healthcare Payor – Simplify prior authorization(PA)

Available with: Microsoft 365 Copilot and Copilot Studio

Healthcare scenario: Payor – Simplify prior authorization(PA)

Back to Healthcare Scenarios Download scenario guide

Scenario

Provide faster service that is easier for member to understand

1. Summarize request

Use a Copilot agent to summarize relevant information for the incoming PA request by analyzing relevant information from prior authorization forms, medical records, and coverage policy documents.

Copilot Studio icon

Copilot Studio Agent

Benefit: Reduces manual effort and ensures comprehensive data extraction for accurate decision-making.

Use a Copilot agent to compare and validate identified services against prior authorization guidelines by extracting information from medical records and coverage policy documents.

Copilot Studio icon

Copilot Studio Agent

Benefit: Helps ensure compliance with guidelines and improves the accuracy of service validation.

Utilization Management (UM) team members use Copilot Pages to collaboratively review/ refine and have interactive discussions on summarized information on incoming PA request.

Microsoft Copilot icon

Microsoft 365 Copilot Chat2

Benefit: UM team can collaboratively review a comprehensive summary, thus reducing time in understanding member’s prior history.

Use the agent to offer detailed considerations designed to assist UM team members with decision making around approval, denial, or pend status. This can be based on specified rules and guidelines and past decisions on similar cases.

Copilot Studio icon

Copilot Studio Agent

Benefit:  Streamlines the decision-making process and ensures consistency in authorization decisions.

Upon final decision being made, use the agent to draft an authorization letter in the member's preferred language based on the suggested template to include a member summary, and appropriate denial codes, etc.

Copilot Studio icon

Copilot Studio Agent

Benefit: Enhances member experience by providing communication in their preferred language and required timeline.

KPIs

Opportunity to impact key functional area KPIs

How Microsoft Copilot can help improve product time to market

The time spent on drug research and trials. Reducing time to market can reduce costs and accelerate revenues.
Boost productivity
  • Rapidly find information
  • Diagnose problems faster
  • Check for similar issues and resolutions
  • Quickly send follow-up communications

How Copilot can help to reduce claims processing time

This KPI measures the average time to process a claim and can impact patient satisfaction.
Respond to a claim
  • Create richer, faster responses to claims
  • Have Copilot assist with drafting and summarizing emails
  • Simplify finding information for claims responses

How Copilot can help to reduce wait times

This measures the average time a patient waits before receiving care. It’s calculated by dividing the total wait time by the number of patients.
Reduce waiting
  • Address more queries in less time
  • Personalize solutions
  • Improve staff availability based on automated capacity-based scheduling
  • Diagnose problems faster

How Copilot can help to reduce readmission rates

This measures the percentage of patients who are readmitted to the hospital within a specific time frame after being discharged.
Reduce churn
  • Address more queries in less time
  • Personalize solutions
  • Improve staff availability based on automated capacity-based scheduling
  • Diagnose problems faster

How can Copilot improve patient retention

This KPI measures the percentage of patients who return to the same healthcare facility for future care.
Reduce churn
  • Address more queries in less time
  • Personalize solutions
  • Improve staff availability based on automated capacity-based scheduling
  • Diagnose problems faster

The content in this example scenario is for demonstration purposes only. You should evaluate how Copilot aligns with your organization’s business processes, regulatory requirements, and responsible AI principles.