Transforming Prior Authorization for Adaptive Biotechnologies

Executive Summary

‍Adaptive Biotechnologies (NASDAQ:ADPT), a leader in NGS-based minimal residual disease testing, successfully transformed its prior authorization process through an intelligent automation partnership with Sample Healthcare. Key achievements include:

• Increasing prior authorization success rates from 40% to over 70%
• Reducing staffing needs by 65%, from an estimated 20+ full-time employees down to 7, while simultaneously doubling prior authorization coverage across 3^rd party pay orders
• Completing implementation within weeks, followed by continuous optimization to continue to automate and improve the level of effort needed to initiate each PA. Additional optimization included integrating with a third-party eligibility and insurance discovery vendor to confirm insurance details in-house, as well as LLM-assisted patient information summarization
• Reduced time to submit each PA package from 15 minutes per PA to less than 5 minutes
• Recovering incremental 7-figure annual cash collections through higher authorization success rates
• Reduced incidence of prior authorization denials by 60-70%
• Eliminated 100% of DOS/no retro auth PA denials by moving the PA process upstream in the order-to-result process.
• Seamless integration with internal data warehouses, laboratory systems, order management, and external authorization networks

This case study illustrates how sophisticated automation can revolutionize healthcare operations—improving outcomes and scaling efficiency without compromising compliance.

The Challenge‍

Adaptive Biotechnologies faced escalating reimbursement hurdles for its NGS MRD services. Outsourced prior authorization processes caused extensive revenue leakage, driven by delays, inconsistent clinical documentation, and payer submission errors.

Early investigations revealed that poorly executed authorizations were costing the organization seven figures annually in lost revenue. An initial plan to bring the entire process in-house projected a need for at least 20 full-time employees—an unsustainable model in terms of both operational cost and complexity.

The Transformation‍

To address these challenges, Adaptive partnered with Sample Healthcare to deploy a unified automation platform. By directly integrating with the client’s data warehouse, Laboratory Information Management System (LIMS), and order management tools, the platform minimized manual data gathering. It also connected to external eligibility and prior authorization networks, creating a single, cohesive workflow.

Sample Healthcare’s flexible logic builder allowed the client’s subject-matter experts to encode payer-specific rules for each diagnostic test offered by the client. This ensured that the system automatically generated and routed prior authorization packets—complete with custom cover letters, policy references, and supporting documentation—along the optimal evidence and collateral for each payer. The platform’s intelligent clinical language models further enhanced efficiency by extracting relevant information directly from patient records to include on submitted prior authorization packets.

The initial implementation occurred within weeks while preserving operational continuity. API integrations were made between need order management, authorization and billing systems. Automations handled complex tasks such as collecting documentation, assembling authorization packets, and reconciling payer submissions, all while maintaining the strict requirements of healthcare compliance.

Impact and Results‍

Upon launching the automated prior authorization solution, the client achieved an immediate 65% reduction in required staffing levels, falling from a projected 20+ full-time employees to just 7. Simultaneously, the authorization success rate surged from 40% to more than 70%, recapturing substantial revenue that previously slipped through the cracks.

These gains extended beyond mere cost savings: the automated process consistently adhered to payer-specific rules without sacrificing accuracy. By eliminating manual bottlenecks and errors, the system enabled higher-volume processing at superior success rates—helping the organization fully realize the revenue potential of its testing services.

Key Success Factors

1. Flexible Platform Configuration: The ability to encode the client’s expertise into automated workflows ensured payer and policy requirements were precisely addressed.‍
2. Seamless Systems Integration: Direct connections to the client’s data warehouse, LIMS, and order management systems enabled a continuous information flow, reducing manual data entry.‍
3. Real-Time Operational Insights: Built-in observability tools provided granular performance metrics, allowing the organization to optimize submissions and maintain a cycle of continuous improvement.

Looking Ahead‍

After rapidly stabilizing and improving prior authorization, the organization is now expanding its use of Sample Healthcare’s platform to streamline appeals, denials management, and broader clinical operations. As the healthcare landscape evolves, the client remains well-positioned to adapt quickly, bolstered by a robust, intelligent automation system that supports both compliance and scaling.

About Sample Healthcare

Sample Healthcare specializes in helping healthcare organizations safely deploy AI to accelerate clinical operations. Their platform enables healthcare providers to transform complex administrative processes through intelligent automation while maintaining compliance and accuracy. By focusing on seamless integration with existing systems and workflows, Sample Healthcare helps organizations achieve dramatic improvements in efficiency without disrupting critical operations.