While many of the patient access workflow processes have been automated with great success, prior authorization automation has remained largely an aspiration. Insurance verifications and eligibility modules have been successfully launched in many hospital and practice settings (over 84% according to the latest 2020 CAQH Index), while prior authorization automation has lagged (only 21% by comparison).
It’s time for an innovative disruption where prior authorization workflow can be reimagined to include artificial intelligence (AI) solutions coupled with human intelligence in the form of certified billing specialists to handle complex or emergent cases.
Automating Prior Authorizations – A Successful Scenario
Infinx aligned with a large East Coast hospital-based orthopedic group with over 70 providers at 11 locations providing orthopedic services, as well as imaging, rehabilitative therapy, pain management, and primary care services. With a variety of studies being scheduled through their diagnostic imaging location, including MRIs, CT Scans, Ultrasounds, and Full Body Dexascans, they had their hands full with targeting and isolating health issues, developing prognoses, and initiating treatment in real-time for their patients.
Using the Infinx Prior Authorization Software solution, the hospital-based orthopedic group was able to initiate their prior authorizations in near real-time and has proven to be the solution with the most benefits.
A Step-by-Step Overview
To outline, the cloud-based and AI-driven software is integrated bi-directionally with the practice EHR/EMR and the billing system used for client management through cloud-based technology. As soon as the patient’s order is input, tests or medications requiring prior authorizations are electronically identified, provider/facility details, patient demographics, and test/diagnosis information collected, and an approval request submitted in real-time to the insurance payer portal.
AI-driven software with machine learning capabilities continually accesses clearinghouses storing thousands of insurance groups and plans, each with their unique guidelines and requirements, and electronically determines the prior authorization parameters for routing the request.
Key Benefits From Automating Prior Authorizations
These are some of the benefits that were recognized by the orthopedic group:
- Initial Processing — From the moment patient information is entered into the EHR/EMR system, guided processes were monitored for the key identifiers to initiate prior authorization approval. Matching ordered tests or medications with constantly updating insurance prior authorization requirements, the system stands ready to gather the required information and submit the request in real-time.Business or clinical staff no longer have to manually process forms, wait on hold, or fax repeatedly and can refocus their time on higher-level functions.
- Continual Follow-Up — Once the prior authorization approval is submitted, electronic follow-up occurs 24/7 until a final resolution was obtained. If additional information is required or an appeal necessary, the practice was notified immediately so that a response could be crafted and submitted as soon as possible.
- Dashboard Notifications — Waiting for insurance payer responses has historically been a time-consuming affair that took hours of follow-up and burdensome administrative effort. With an interactive dashboard, today’s AI-driven software gives a complete snapshot and clarity on all active prior authorization requests so that patient and clinician questions can be answered immediately, and follow-up can occur, as necessary.
- Scheduling — Alleviating the frustrations of having to schedule and reschedule patients based on prior authorizations, the orthopedic group had more accurate parameters allowing a more efficient process for everyone. This improved the patient’s experience and let the providers focus on care.
- AR and Claims Management — With fewer prior authorization problems comes less rejected or denied claims, and more revenue hitting the bottom-line. As a bonus, Infinx has an AR Optimization Solution software that handles denied claims, like the Infinx Prior Authorization Software solutions with a >95% quality standard.
- Analytics and Reporting — Bringing full transparency to future operations, timely analytics, and reporting pinpointed breakdowns in efficiency or areas needing improvement. This allowed the orthopedic group to reallocate workflows to other areas to allow for more work to get done overall.
To Sum Up
As reliance on automated prior authorizations continues to grow, differentiating your hospital or department from others by offering pristine business support to referring providers or self-referral patients helps secure future potential patient growth. Your hospital or department will see the benefit to their patients with more timely care initiation and less cumbersome reimbursement.
Contact Infinx to schedule a demonstration and learn more about the automated prior authorization journey’s efficiencies for your hospital or healthcare system.