hakish/pre_auth_prediction_engine

This repository is created by Kishore Hariharan to save all the artifacts of the pre authorization project

This repository contains the project work submission for the Big Data and Analytics course. 
I have built a Pre-Authorization prediction engine that uses machine learning for the health and insurance industry with a fabricated dataset.

The purpose of the project is:
▪ To create an analytics engine for doctors which has the capability to make predictions as to whether a drug would require Prior Authorization(PA) from the health plan company or not.
▪ To understand what factors and conditions result in an approval and denial of a PA request.
▪ To see if there is a relation between formulary status of the drug and PA approval.
▪ To learn how advance machine learning techniques can be used for making predictions.

■State-Of-The-Art

➢ What Is Prior Authorization for Prescription Drugs?
Prior Authorization (PA) is a requirement from your insurance company to your physician. The physician must get specific medications (or operations) approved by the insurance company before the insurance company will provide full (or any) coverage for them. Prior Authorization may also be referred to as Pre-Authorization, Prior Approval or Precertification. Failure to obtain these proper permissions may affect claim payment, subject to the terms and conditions of a Coverage Plan. A PA is not a guarantee of benefits or payment. A failed authorization can result in a requested service being denied, or an insurance company requiring the patient to go through a separate process known as Step Therapy or Fail First. Step therapy dictates that a patient must first see unsuccessful results from a medication or service preferred by the insurance provider, typically considered either more cost effective or safer, before the insurance company will cover a different medication.
Most health insurance plans come with a Drug Formulary. A drug formulary is a list of prescription drugs, both generic and brand name, used by practitioners to identify drugs that offer the greatest overall value. A committee of physicians, nurse practitioners, and pharmacists maintain the formulary. It has been observed that the PA requests for drugs in the formulary has a higher chance of being approved as opposed to non-formulary drugs.

➢ Why Do Insurance Companies Require Prior Authorization?
In short, health insurance companies pre-authorize medications in order to keep healthcare costs low. By ensuring that your medication is medically necessary, up-to-date, as economical as possible, and isn’t being duplicated, health insurance companies can afford to provide more expensive medications to those who truly need it.

➢ What Kinds of Medications Warrant Prior Authorization?
There are several reasons a medication may require a prior authorization request. For example, the prescription may:
▪ be a brand name medication that is available as a generic
▪ be expensive (as with psoriasis and rheumatoid arthritis medications)
▪ be used for cosmetic reasons (as with hair growth and wrinkling treatments)
▪ be used at higher doses than normal
▪ treat non-life threatening conditions not usually be covered by the insurance company, but is deemed medically necessary by the physician (who must also inform the insurance company that no other covered medications will be effective)