# Insurance Verification & Prior Authorization: done-for-you AI automation by BufferSol

> A done-for-you insurance verification and prior authorization automation is an AI agent that checks each upcoming patient's coverage, works out whether the ordered service needs approval, assembles the documents the payer asks for, and submits and tracks the request through electronic channels and payer portals. Your staff review every submission with clinical content before it goes out. BufferSol builds, connects and configures it inside your EHR and clearinghouse, and it is live in 3 to 6 weeks.

- Canonical: https://buffersoltech.com/done-for-you/healthcare/insurance-verification-prior-auth
- Category: Healthcare & Clinics
- Provider: BufferSol Technologies (New York; serving the US, UK, Ireland, Canada and the EU)
- Timeline: live in 3 to 6 weeks
- Pricing: quoted after a short scoping call

## Coverage checked and prior auths filed before the patient is on the schedule

**Who it is for:** Specialty practices, imaging and infusion centers, surgical groups and multi-site clinics that run dozens of prior authorizations per physician each week and still verify coverage by portal and phone.

### Signs you need it
- Some staff work only on prior authorizations and still fall behind.
- Patients learn about a denied or missing authorization on the day of the procedure.
- Eligibility is checked at the first visit but rarely re-checked before follow-ups.
- Your team spends hours on hold with payers or logging into a different portal for each plan.
- Claims come back denied for missing authorization numbers or lapsed coverage.

## Business outcomes
- **Fewer day-of surprises.** Coverage, benefits and authorization status are known before the visit, so neither the patient nor the front desk finds out at check-in.
- **Complete requests the first time.** Requests go out with the right forms and attachments, which cuts the back-and-forth that keeps cases pending.
- **Staff on the hard cases.** Your authorization team spends its time on peer-to-peer reviews, appeals and complex cases instead of status calls.

## How it works today
1. A coordinator pulls tomorrow's schedule and checks each patient's eligibility in Availity, a payer portal or by phone.
2. For each ordered service, they look up whether that plan requires prior authorization, often in a payer PDF or an internal spreadsheet.
3. They gather notes, imaging and lab results from the EHR and fill in a payer-specific form or portal screen.
4. Requests go out by portal, fax or phone, and status is tracked in a spreadsheet or on sticky notes.
5. Staff call payers to chase pending cases and reschedule patients when approval does not arrive in time.

Hidden costs:
- Delayed approvals push procedures back, and some patients give up on the treatment altogether.
- Missing or expired authorizations turn into denied claims that take even more staff time to appeal.
- Skilled staff spend their day on hold, which drives burnout and turnover in a hard-to-hire role.

## How it works done for you
1. Each night the agent reads upcoming appointments and orders from the EHR and runs electronic eligibility checks through your clearinghouse, such as Waystar or Availity.
2. It compares each order with the payer authorization rules your team maintains and marks which cases need a request, which are exempt and which are unclear.
3. For cases that need one, it pulls only the records that payer requires, drafts the request and fills the electronic prior authorization form or portal screen.
4. A staff member reviews any request with clinical content and approves it before submission; the agent never judges medical necessity.
5. It checks status on a schedule, records reference numbers and decisions in the EHR, and alerts staff when the payer asks for more information or a peer-to-peer review.
6. Patients get a plain-language update on coverage or a delay, and schedulers see which visits are cleared to go ahead.
7. Every eligibility response, submission, status check and approval is logged for audit and appeals.

## What changes for the team
- **Prior authorization coordinator.** Today: Filling payer forms, attaching notes and calling for status all day. Done for you: Reviewing drafted requests, handling peer-to-peer reviews and appeals, and updating payer rules when they change.
- **Registration staff.** Today: Checking eligibility visit by visit and breaking news of surprise costs at check-in. Done for you: Seeing a cleared or flagged status on each visit and talking to patients only about real issues.
- **Revenue cycle manager.** Today: Tracing denials back to missing authorizations after the fact. Done for you: Watching a live queue of pending cases and payer turnaround, and fixing patterns early.

## KPIs we measure
- **Authorization turnaround:** Days from order to approval, by payer and service, baselined from the last quarter.
- **First-pass approval:** Share of requests approved without a request for more information.
- **Authorization-related denials:** Denials for missing or invalid authorization, tracked monthly from clearinghouse remits.
- **Eligibility on file before the visit:** Share of scheduled visits with a current eligibility response two days ahead.
- **Staff hours on authorizations:** Weekly hours from a time study before launch and from the agent's activity log after.

## Industry data
- 39: prior authorization requests per physician, per week, on average (AMA survey of 1,000 physicians, late 2024) ([American Medical Association](https://ama-assn.org/practice-management/prior-authorization/fixing-prior-auth-nearly-40-prior-authorizations-week-way))
- 13 hours: spent each week by physicians and their staff completing those requests (AMA survey, late 2024) ([American Medical Association](https://ama-assn.org/practice-management/prior-authorization/fixing-prior-auth-nearly-40-prior-authorizations-week-way))
- 24 minutes: average provider and staff time to request a prior authorization by phone, fax or email, versus 16 minutes by portal (2024 CAQH Index) ([CAQH](https://www.caqh.org/hubfs/Index/2024%20Index%20Report/CAQH_IndexReport_2024_FINAL.pdf))

## Systems it connects to
Epic, athenahealth, eClinicalWorks, NextGen, Availity, Waystar, CoverMyMeds, Payer portals, Microsoft 365

## Guardrails
- Staff approve every request that contains clinical content; the agent drafts and submits but never judges medical necessity.
- A BAA is in place with BufferSol and every downstream vendor, and PHI stays in your approved environment.
- Minimum-necessary document pulls: only the records each payer asks for are attached.
- Payer rules are versioned and owned by your team, and any unclear case goes to a person.
- A complete audit trail of eligibility responses, submissions, reference numbers and decisions.

## What teams say about this work
- Physicians report that their practices handle dozens of prior authorization requests per physician every week, and many employ staff who do nothing but prior authorizations. ([American Medical Association](https://ama-assn.org/practice-management/prior-authorization/fixing-prior-auth-nearly-40-prior-authorizations-week-way))
- Practices tell CAQH that complex and changing plan rules, inconsistent data and low electronic adoption make each authorization slow, and urgent cases still end up on the phone while the patient waits in the office. ([CAQH](https://www.caqh.org/hubfs/Index/2024%20Index%20Report/CAQH_IndexReport_2024_FINAL.pdf))
- Most physicians say it is hard to tell whether a service needs prior authorization at all, and phone and fax remain the most common ways requests get done. ([American Medical Association](https://www.ama-assn.org/practice-management/sustainability/prior-auth-survey-findings-underscore-need-legislative-action))
- Physicians link prior authorization delays to patients abandoning recommended treatment and to serious adverse events. ([American Medical Association](https://ama-assn.org/press-center/ama-press-releases/ama-survey-indicates-prior-authorization-wreaks-havoc-patient-care))
- Practice leaders rank eligibility and prior authorization calls, including benefit checks, denials and status calls with long holds, as the most time-consuming phone work their staff do. ([MGMA](https://mgma.com/mgma-stat/phones-are-still-a-backlog-costing-medical-practices-time))

## Delivery: live in 3 to 6 weeks
1. Week 1: discovery, access and a baseline of today's numbers.
2. Weeks 2–3: build the agents and connect your systems, with your rules and approvals.
3. Weeks 3–5: test on your real history, then pilot on live work with your team reviewing.
4. Weeks 4–6: staged go-live, training, dashboards and handover.

## Executive Ask questions for this workflow
- Which procedures next week are still waiting on prior authorization, and from which payers?
- Which payers took longest to approve requests this month?
- How many claims were denied for missing authorizations last quarter, and what did they have in common?

## Frequently asked questions
### Does the AI decide whether a service is medically necessary?
No. Medical necessity and anything clinical stay with your clinicians and authorization staff. The agent gathers the records the payer asks for, drafts the request and fills the forms, then a staff member reviews and approves it before submission. It also flags cases where the payer rule is unclear instead of guessing. Every approval is logged with the reviewer's name and the time.

### Does it work with electronic prior authorization and payer portals?
Yes. Where a payer supports electronic prior authorization through your EHR, CoverMyMeds or a clearinghouse, the agent uses that route. Where a payer only offers a portal, it works the portal under a dedicated account you approve. For payers that still need fax, it prepares the packet and sends it through your fax service. As more payers add APIs, the same agent switches over.

### How do you handle HIPAA?
We sign a Business Associate Agreement before any work with PHI, and every model and hosting provider involved is covered by one. The agent uses minimum-necessary access: it reads orders, coverage and the specific records a payer requires, nothing more. Access runs through named service accounts, data stays in your approved environment, and every read and write is logged for your compliance team.

### How long until it is running?
It is live in 3 to 6 weeks. We start with your top payers and highest-volume services, load the authorization rules your team uses today and connect the EHR and clearinghouse. Then the agent runs alongside your coordinators on real cases, with staff approving every submission, before we add more payers and service lines.

### How much does it cost?
It depends on your volume, the number of payers and portals, your EHR and how many service lines are in scope. We map your current process on a short scoping call and then send a fixed written quote. There is no price on this page because every practice's payer mix is different; the quote is sent after that short scoping call.