Surgical Outpatient Network Reduced Time for Prior Authorization by 46%

The Solution

An AI-Assisted Prior Authorization Platform Built with Quickbase, Workato, and Claude

Quandary Consulting Group designed and implemented a centralized prior authorization operations platform using Quickbase, Workato, and Claude. The solution coordinated the entire administrative authorization lifecycle while connecting employees with the clinical, insurance, and operational information required to process each request.

Centralized Authorization Management in Quickbase

Quickbase became the organization’s central operations platform for managing prior authorizations across every location and state. Each authorization was captured in a standardized record containing:

• Patient and appointment information
• Treating location and assigned provider
• Insurance plan and payer
• Diagnosis and procedure codes
• Requested therapy services
• Number and frequency of requested visits
• Required clinical documentation
• Submission and follow-up dates
• Authorization status
• Approved visit limits
• Effective and expiration dates
• Denial and appeal information
• Assigned authorization specialist

Every request moved through a clearly defined workflow, from initial identification and documentation review through payer submission, approval, denial, escalation, or renewal.

Role-based work queues showed employees exactly which cases required their attention. New requests were routed to the correct authorization specialist based on payer, location, state, and service type. Managers could reassign work when volumes increased or employees were unavailable.

Dynamic Payer Documentation Checklists

Quandary configured documentation checklists that adapted to the requirements of each payer, plan, and treatment type. When a new request entered the platform, the system identified the applicable requirements and generated a tailored checklist. Depending on the authorization, required materials could include:

• Physician referrals or orders
• Initial evaluations
• Treatment plans
• Progress notes
• Diagnosis and procedure codes
• Medical-necessity documentation
• Functional assessments
• Prior treatment history
• Requested visit frequency and duration
• Supporting imaging or specialist records

The platform prevented incomplete cases from being treated as submission-ready. If documentation was missing, the request entered an exception workflow that identified the outstanding item, assigned responsibility, and generated follow-up reminders.

This helped employees resolve documentation gaps earlier—before they delayed a scheduled appointment or caused an avoidable denial.

AI-Assisted Administrative Review with Claude

Claude was incorporated as an assistive document-intelligence layer. It helped authorization specialists review approved clinical and administrative materials without independently making coverage, clinical, or submission decisions. Claude analyzed available documents and created a concise case summary containing relevant information such as:

• Primary diagnosis
• Functional limitations
• Requested rehabilitation services
• Treatment frequency and duration
• Prior response to therapy
• Documented medical necessity
• Progress toward established goals
• Relevant payer requirements
• Potentially missing or inconsistent information

Claude compared the available materials with the applicable documentation checklist and highlighted items requiring employee review. It also prepared draft authorization narratives using information contained in the approved patient record.

Qualified employees reviewed every AI-generated summary and draft before it was used. Authorization specialists retained full authority over the final narrative, supporting documentation, payer submission, escalation, and appeal. This human-in-the-loop structure increased administrative efficiency while protecting professional judgment and accountability.

Workflow Orchestration + Workato Integrations

Workato connected the authorization platform with the organization’s existing clinical, scheduling, document-management, and communication systems. Automated workflows transferred approved information between systems and triggered the appropriate action when an authorization changed status. Depending on the workflow, Workato could:

• Create an authorization request when qualifying care was scheduled.
• Retrieve approved patient, payer, and appointment information.
• Route clinical documents to the correct authorization record.
• Notify specialists when documentation became available.
• Update scheduling teams when authorization was approved.
• Alert employees when additional payer information was requested.
• Escalate requests approaching internal turnaround-time thresholds.
• Trigger renewal workflows before approved visits were exhausted.
• Record authorization status changes in connected systems.

This integration reduced duplicate data entry and helped ensure that authorization, clinical, and scheduling teams worked from consistent information.

Proactive Exception and Expiration Management

The platform continuously monitored requests for conditions that could affect scheduled care. Automated alerts notified employees when:

• Required documentation was missing.
• A payer had not responded within the expected timeframe.
• An authorization was approaching expiration.
• Approved visits were nearly exhausted.
• A scheduled appointment lacked confirmed authorization.
• A request was denied or required additional information.
• A case remained inactive beyond an established threshold.
• An appeal or peer review required action.

Instead of manually checking every open request, employees could concentrate on exceptions with the greatest operational or patient-care impact.

Leadership Dashboards and Governance Controls

Quickbase dashboards gave managers and executives real-time visibility into prior authorization operations across the five-state network. Leadership could monitor:

• Authorization volumes by payer, state, clinic, and service type
• Pending and aging requests
• Average turnaround time
• Upcoming expirations
• Delayed appointments
• Approval and denial rates
• Common denial reasons
• Requests requiring additional documentation
• Employee and team workloads
• Payer response trends
• Renewal and appeal activity

Role-based security limited employees to the information required for their responsibilities. Detailed histories documented assignments, status changes, notes, approvals, AI-assisted outputs, employee validation, and submission activity.