AI-Driven Software: Providing Complete Prior Authorization Coverage for Healthcare Providers

By Navaneeth Nair
March 25, 2019

In the fight between health insurers and patients, I have seen that healthcare providers are caught squarely in the middle, which can be a costly position.

The provider’s battle begins before the patient enters the medical facility. Studies show that providers can spend as many as 20 hours a week getting preauthorization for their patients. It is a lengthy process that can cost each provider an average of $83,000 annually, and that figure can increase when you factor in lost productivity.

The battle often continues long after the patient has been seen. According to recent studies, a provider can lose more than 3% of patient revenue due to insurance company denials. Nearly a quarter of those denials are related to patient eligibility. While most denied claims can be recovered through the appeals process, the cost to appeal can be as high as $120 per claim.

As VP of Product for Infinx, I have been working on solving these issues through an artificial intelligence (AI) driven software solution that covers 100% of prior authorizations because it is backed up with exception handling by certified prior authorization and billing specialists.

Helps Determine If Prior Authorization Is Required

Our software evaluates all procedures to be performed and determines if prior authorization is required. As insurers keep changing their policies, the machine learning algorithms learn and adapt to these changes. This Prior Authorization Determination Engine feature is a new product update that just launched and was demonstrated at the HIMSS19 trade show in Orlando.

The determination allows providers to schedule the patient as soon as possible, which improves the overall patient experience in most cases.

Our solution also can help identify if the prior authorization request requires a clinical review; the software also accurately predicts the turnaround time for a specific case so providers can give the best possible schedule to their patients.

Electronically Submits Prior Authorization Requests With Exception Handling By Specialists

If a given procedure requires prior authorization, the provider can electronically submit the request to all payers using a single web portal or integration with Infinx, reducing the need to make multiple calls or send documents to different insurance companies. This eliminates the need to log into multiple individual payer portals.

The authorization requests can be electronically transmitted using integration or robotic automation, and Infinx prior authorization specialists are available to perform manual submissions in complex scenarios or if payer does not support electronic submissions.

Automatic Status Updates Ensure Procedures Get Scheduled On Time

Once the authorization requests are submitted, the software provides clients with an authorization reference number and constantly follows up with payers using an automated process that provides real-time updates as soon as a payer gives approval.

The solution continuously evaluates the follow-up against the scheduled date of service and turnaround risk, and we are able to intelligently engage our prior authorization specialists if follow-up with the payer is necessary to ensure authorization before service is rendered.

Alleviates Administrative Burden, Patient Scheduling Anxiety & Financial Risk

Infinx’s AI-driven Prior Authorization Software supports providers by eliminating the administrative burden of obtaining prior authorizations. Additionally, the solution provides insights that help providers improve the patient procedure scheduling experience without the financial risks of performing procedures without insurance company approval.

For more information, visit https://www.infinx.com.

About the Author

Infinx

Infinx

Infinx provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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