Given the weighty burden prior authorizations inflict on sleep medicine providers and their patients, the American Academy of Sleep Medicine (like most specialty organizations) is advocating for changes in this critical patient access process. Along with the AMA, they are pushing for more long-term authorizations and for authorizations to be shared among payers should a patient change insurance plans.
Despite the nationwide call for fewer prior authorization regulations, providers still find they can’t carry out this critical patient access in a timely or accurate manner. Complexities and confusion often lead to patient care delays (up to three weeks) and force providers to change treatment plans. Both interfere with ideal outcomes for sleep patients, many of whom are already suffering significantly when they arrive for their first appointment.
One midwestern sleep clinic found they were getting behind in their prior authorization submissions. This clinic helps patients by providing both medical services from sleep specialists and medical equipment. Their CPAP and BiPAP machines for obstructive and complex sleep apnea are among their most popular therapies. They also provide travel CPAP machines, smaller CPAP nasal masks, full face masks. They treat a wide range of sleep disorders including sleep apnea, narcolepsy, insomnia, and restless leg syndrome.
Staffing Shortage Slows Prior Authorization Submissions
With the pandemic-triggered staffing shortage, the client found that the volume, variability, and unreliability of payer requirements were straining their resources and limiting revenue. They could not find certified staff who could properly code and bill the first time and manage denials promptly. Further, because they were manually entering all prior authorizations, their prior authorization costs were high.
As we discuss in this blog post, sleep clinics make the prior authorization process work when they:
- submit organized, sufficient documentation
- are prepared for clinical review on in-clinic or assisted studies
- consider an automated prior authorization process
But insufficient staff at this clinic often made these steps impossible. Convinced by a fellow sleep medicine group that automation and trained specialists could help them get prior authorizations in on time and accurately, they began a search for a solution. This other clinic recommended Infinx.
Infinx Begins Work On Prior Authorization Challenges
We started exploring the client’s prior authorization process and patient data immediately.
Our prior authorization software uses AI to automate repeated tasks with workflow optimizations. Any exceptions that occur in the prior authorization process get handed off to our team of prior authorization specialists who find a way to push prior authorizations through. These specialists achieve very low denials rates.
We were able to seamlessly integrate with the provider’s teams, and the new prior authorization software was integrated with little disruption to day-to-day operations. We instilled high IT standards and provided flexibility for the team specifically.
Once the provider uploaded their information manually into our portal, we filtered through and sorted it. The client can access the information on an as needed basis.
Our team regularly meets with the provider to evaluate how well the prior authorization solution has been working for them, discuss changes to payer requirements or specifics about certain cases.
No Need For New Staff With Prior Authorization Solution
Since joining our team, the client has heavily relied on the prior authorization solution. They use our team as their primary prior authorization staff. Their efficiency has increased dramatically, while their need for staffing resources and physical space has decreased. Both improvements led to lower overhead costs. Extremely satisfied with this product, the client has been using it for the past few years with no issues.
If you are looking to achieve similar results at your organization, contact us at www.infinx.com/request-a-demo.
Looking to grow your revenue without hiring more staff? Explore how one growing East Coast radiology network offered local providers free prior authorization services as an enticement to partner.