100%
Observability &
Visibility
3x
75%
Reduced Admin
Effort
Overview
A multi-speciality healthcare provider managing thousands of patient referrals annually was struggling with a highly manual referral authorization process. Care coordinators spent significant time verifying insurance eligibility, obtaining prior authorizations, assembling clinical documentation, and coordinating communications between patients, providers, and specialists
Business Challenge
The organization sought to streamline referral management, reduce administrative burden, and improve patient access to specialty care while maintaining compliance and operational visibility. Coordinators frequently switched between payer portals, EHR systems, fax services, and communication tools to complete a single referral.
01
Lengthy referral turnaround times delaying patient care.
02
High coordinator workload caused by manual eligibility checks and authorization requests.
03
Inconsistent documentation packages leading to referral rework.
04
Limited visibility into referral status and exception handling.
05
elsai Solution
elsai deployed a governed agentic workflow that automated referral authorization and referral management across the healthcare provider's existing ecosystem.
Key elements of the solution included:
• Automated insurance eligibility verification using payer integrations.
• Intelligent identification of in-network specialists based on specialty and location criteria.
• Assisted prior authorization workflows with pre-prepared documentation and authorization tracking.
• Automated referral creation and population of mandatory EHR fields. AI-powered assembly of clinical documentation from EHR, HIE, laboratory systems, and faxed records.
• Automated referral transmission with delivery tracking and retry mechanisms.
• Real-time patient notifications through SMS and digital messaging channels.
• Automated quality-control checks to ensure referrals were complete before closure.
Business Impact
75% reduction in coordinator administrative effort.
70% of referral activities automated through agentic workflows and 10-step referral process streamlined across a unified workflow.
50–60% faster referral turnaround, reducing average processing time from 5–12 days to 2–4 days.
100% referral audit trail visibility across intake, authorization, transmission, and closure.
3x improvement in referral processing capacity without increasing staffing levels.
The elsai Advantage
• Seamless integration with existing EHR and payer ecosystems.
• Human-in-the-loop governance for critical healthcare decisions.
• Automated exception handling and escalation management.
• End-to-end referral visibility with complete audit trails.
• Reduced administrative burden without disrupting existing processes.
