Maximizing the patient access workflow for orthopedic practices is of paramount importance, and finding innovative ways to capture every dollar due is critical. According to the Centers for Medicare & Medicaid Services (CMS), consumer households were responsible for 28.4% of the total National Healthcare Expenditure (NHE) of $3.6 trillion in 2018. CMS further noted that those figures are expected to climb on average by 5.5% per year.
- It’s never been more imperative to review your operational processes that relate to patients accessing care when first presenting for treatment. Two questions immediately jump to mind: how much time is medical, clinical, and administrative staff spending to manage the process and are there more efficient options, and
- is it possible to get more accurate results that can improve reimbursement in a significant way?
An Innovative Way Forward
Through state-of-the-art automation and AI-driven machine learning capabilities, ortho practices can find significant relief from the burdens of prior authorization (PA) and capture additional revenue through reduced denials and insurance discovery. Let’s look at the components of the whole.
Insurance Verification and Patient Pay Estimation
Automated insurance verification and patient pay estimation allow real-time eligibility and benefits information to be gleaned for patients before they visit the practice and present for treatment. By understanding a patient’s benefits and what deductibles have been met, along with out-of-pocket maximums and co-pays, your practice can collect an estimated patient portion due before the work has been performed.
With robust training and clear expectations set, your front office staff can be empowered to present options to patients and manage the overall business in line with pre-determined financial policies. As patients continue to absorb a larger and larger share of the financial responsibility for their care, they are keenly aware of dollar amounts and appreciate an upfront discussion that allows them to understand their costs.
What if your practice could get faster approvals using automation and AI-driven prior authorization technology that allows submission, follow-up, and appeals in real-time and reduces the human factor to almost zero? Through a multi-dimensional and fully integrated system, most PAs can be handled with the information available through clearinghouses and insurance payer portals. And once approvals are obtained, the system would notify the scheduling department so that patients could secure their procedure time, and everyone would be confident in financial expectations on all fronts.
Instead of your staff spending hours on hold, this process can be automated through completion in minutes rather than days with any outliers or emergent requests being handled by a team of third-party experts.
Clinical Decision Support Mechanism
In 2020, as part of PAMA, advanced imaging services are being subjected to an Appropriate Use Criteria (AUC) process that ends in the referring provider issuing a certificate to the performing radiology group to ensure payment for Medicare patients. With imaging, the lifeblood of the diagnostic process for orthopedics, the Clinical Decision Support Mechanism (CDSM) fully integrated into a prior authorization package would ensure compliance and support your colleagues in radiology who face non-payment beginning in 2021.
While not a part of the patient access process, insurance discovery brings AI-driven automation to the bad debt conversation and tackles problems that may have originated when the patient first presented for treatment.
In the complex world of healthcare reimbursement and insurance coverage, ortho practices are reliant on the information obtained from patients. Sometimes, through no fault of anyone, there are omissions that affect the amounts received. With an AI-driven insurance discovery solution, previously unknown coverage can be detected and claims resubmitted with a collection rate well above 50%. The insurance discovery process works especially well with Medicaid and commercial payers, plus the value-added benefit to the patient who is unaware of the coverage.
Whether you are looking at automating the orthopedic prior authorization or AI-driven insurance discovery workflows, it’s important to recognize the potential impact on the group. Each of these represents an opportunity to streamline operations, improve the patient experience, and positively impact the bottom-line.
Contact us to learn more about our patient access and insurance discovery solutions and the ways it can improve your overall financial performance.