CASE STUDY

An AI-Powered Prior Authorization Solution Implemented For An East Coast Orthopedic Group Achieved A $55K Increase In Quarterly Revenue

The Background

Infinx partnered with a large East Coast Orthopedic Group (the Group) with over 70 providers at 11 locations providing orthopedic services, imaging, rehabilitative, pain management, and primary care services. The Group offers various studies through their diagnostic imaging location, including MRIs, CT Scans, Ultrasounds, and full body DEXA scans, to target and isolate issues, develop prognoses, and initiate treatment for their patients.

The Challenge

Due to operational complications from a manual prior authorization process, the Group saw significant revenue leakage caused by their overburdened Patient Access team. Scheduling patients for diagnostic imaging studies took up to 21 days, leaving patients and referring providers frustrated. This lag time caused patients to move their care to other practices that could obtain insurance approval in a more timely fashion.

In addition, the Group was also impacted by the industry-wide problem of everchanging payer guidelines. As their diagnostic and treatment abilities evolved and grew, so did the insurance prior authorization requirements. As with many healthcare providers using manual prior authorization systems, they struggled to keep up with administrative guidelines changes coming from a myriad of payers.

Once the structural problems were identified, the Group moved quickly to evaluate their options and institute a solution.

Cost to Sustain a Manual Prior Authorization Process

  • On average, practices complete 33 prior authorizations per physician, per week
  • Physicians and their staff spend an average of almost two business days (14.4 hours) each week completing prior authorizations
  • Almost one-third of physicians have staff who work exclusively on prior authorizations
  • In lost revenue annually per physician

The Pilot

The Group initially partnered with Infinx through a 30-day pilot program before fully committing to the contract, which gave them time to evaluate the results Infinx attained, and to facilitate stakeholder participation and acceptance further guaranteeing success. The Group cited the following components as outstanding selling points:

  • Advanced artificial intelligence (AI)-driven automation software, leveraged by experienced prior authorization specialists, worked in conjunction seamlessly with their MEDENT EHR system to determine if a prior authorization was required. If so, the claim was submitted to the insurance payer, followed-up, and scheduling team notified in real-time when approved.
  • Costs for the software plus specialists were an all-inclusive transactional price based on volume.
  • Ability to scale as their prior authorization volume increase, or if there was a fluctuation in patients, without an impact on the Group’s staff.
  • An extensive knowledge base of orthopedic data within the AI-driven, Prior Authorization Software, that continues to expand and learn through machine learning capabilities. An analytics and reporting dashboard allowed the Group to obtain full transparency and the ability to drill down metrics in real-time.

The Onboarding Process

The Group felt at ease with an implementation process that moved at their desired speed. They were given a single point of contact at Infinx for any issues giving them reassurance that their questions would be quickly and thoroughly addressed.

As a bonus, the reduced administrative time required to manage a manual prior authorization workflow was now focused on adding additional weekend hours, allowing more patient care time and a significant increase in revenue.

The Benefits Achieved

Using the Infinx Prior Authorization Software, as soon as the Group entered in the patient’s order, the prior authorizations were electronically identified. In addition, the provider and facility details, patient demographics, and test/diagnosis information was captured. The claims are then submitted in near real-time to the appropriate insurance payer portals.

The Infinx Prior Authorization Software automatically retrieves national, regional and payer state rules. Our integrated clearinghouse software stores thousands of insurance groups and plans, each with their unique guidelines and requirements, and electronically determines the parameters for routing the prior authorization claims.

These are some of the benefits recognized by the Group after implementing the Infinx Prior Authorization Software solution:

  1. Initial Processing
    From the moment patient information was entered, the Infinx Prior Authorization Software’s guided processes was monitored for key identifiers to initiate the prior authorization claim. 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.The Group’s staff no longer had to manually process forms, wait on hold, or fax repeatedly and could re-focus their time on higher-level functions.
  2. Continual Follow-Up
    Once the prior authorization claim was submitted, electronic follow-up occurs 24/7 until a final resolution is obtained. If additional information was required or if an appeal was necessary, the Group was notified immediately so that a response could be crafted and submitted as soon as possible
  3. Dashboard Notifications
    Waiting for insurance payer responses has historically been a time-consuming affair that took hours of follow-up and burdensome administrative effort. The AI-driven software gives a complete snapshot and clarity on all active prior authorization claims with the interactive dashboard, so that patient and clinician questions are answered immediately, and follow-up can occur, as necessary.
  4. Scheduling
    Alleviating the frustrations of scheduling and rescheduling patients based on prior authorizations not completed in a timely manner, the Group had more accurate parameters and offered a more efficient workflow for everyone. This improved their patients’ experience and allowed the providers to focus on care.
  5. Reduced Claim Denials
    With fewer prior authorization problems came less denied claims and more revenue hitting their bottom line.
  6. Analytics and Reporting
    Bringing full transparency to future operations, timely analytics, and reporting pinpointed breakdowns in efficiency or areas needing improvement. This allowed the Group to reallocate workflows to other areas allowing for more work to get done overall.

The Results

  • Over 600 prior authorizations were processed each month with outstanding results that led to a significant decrease in denial rates and more revenue being collected in a timely manner.
  • Turnaround time for prior authorizations vastly improved, benefiting patient care and satisfaction.
  • Increases were recognized in productivity for their patient access staff, and error rates were greatly reduced, including:
    • Savings of over 80 hours per week, equivalent to $70K+ annually.
    • Ability to see more patients by expanding weekend hours, and a reduced loss of patients to competitors. Due to weekend and extended hours, the Group saw an initial increase in revenue of an additional $55,000 in the first three months.
  • Access to Infinx’s up-to-date payer databases increased efficiencies and reduced their claim denials.

With the outstanding results brought by Infinx’s Prior Authorization Software solution, the Group has recognized significant ROI through staff resource savings and increases to their bottom line. These changes have been viewed positively by the Group stakeholders, and the Infinx relationship has been solidified with an extended contract.

Let Infinx AI help you get faster prior authorization approvals.

Schedule a demo today to learn more about our AI-powered prior authorization software.

      1. Loria K. Putting the AI in Radiology. Radiology Today, Vol. 19, No. 1, P. 10.
        https://www.radiologytoday.net/archive/rt0118p10.shtml.
        Accessed on June 7, 2020.
      2. Carlson B. Molecular Diagnostics Market Now Larger than the Economies of 50 Nations, per New Report. Kalorama Information Website. October 30, 2019.
        https://kaloramainformation.com/molecular-diagnostics-market-now-larger-than-the-economies-of-50-nations-per-new-report/.
        Accessed on January 20, 2020.
      3. Atella V, Mortari A, et.al. Trends in are-related disease burden and healthcare utilization. Aging Cell, 2019 Feb; 19(1): e12681. Published online November 29, 2018. doi: 10.1111/acel.12861.
        Accessed June 1, 2020.
      4. Cohen R, Zammitti E. High-deductible Health Plan Enrollment Among Adults Aged 18-64 with Employment-based Insurance Coverage. Centres for Disease Control and Prevention NCHS Data Brief No. 317. August 2018. https://www.cdc.gov/nchs/products/databriefs/db317.htm.
        Accessed on January 24, 2020.
      5. PAMA Regulations, Important Update. CMS.gov, Centers for Medicare and Medicaid Services.
        https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations
        Accessed on January 28, 2020.
      6. 2018 AMA Prior Authorization (PA) Physician Survey. American Medical Association, Prior Authorization Research & Reports. 2019. file:///C:/Users/katem/Downloads/priorauth-2018%20(1).pdf.
        Accessed on November 23, 2019.
      7. Yu Y, MD. Transforming the prior authorization process to improve patient care and the financial bottom line. MGMA, Knowledge Expansion Insight Article, Reimbrusement.
        https://www.mgma.com/resources/revenue-cycle/transforming-the-prior-authorization-process-to-im.
        Accessed June 10, 2020.
      8. Finnegan J. MGMA19: No progress to fix prior authorization, as practice leaders say it’s gotten worse. Fierce Healthcare. October 16, 2019. https://www.fiercehealthcare.com/practices/mgma19-no-progress-to-fix-prior-authorization-as-practice-leaders-say-it-s-gotten-worse.
        Accessed June 8, 2020.
      9. 2019 CAQH Conducting Electronic Business Transactions: Why Greater Harmonization Across the Industry is Needed, p. 2. 2020.
        https://www.caqh.org/sites/default/files/explorations/index/report/2019-caqh-index.pdf?token=SP6YxT4u.
        Accessed on January 30, 2020.
      10. Joint Authorship. Consensus Statement on Improving the Prior Authorization Process. American Medical Association. 2018. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf.
        Accessed on January 22, 2020.
      11. Letter to the House of Representatives in support of Improving Seniors’ Timely Access to Care Act 2019 (H.R. 3107) from 370 Associations. September 9, 2019.
        https://www.rheumatology.org/Portals/0/Files/Coaliition-Letter-HR3107-Prior-Authorization-Reform.pdf.
        Accessed on January 30, 2020.
      12. Livingston S, Luthi S. House Committee Throws Spotlight on Prior Authorization Burden, Modern Healthcare. September 11, 2019. https://www.modernhealthcare.com/politics-policy/house-committee-throws-spotlight-prior-authorization-burden.
        Accessed on February 3, 2020.
      13. Ibid. 9.
      14. Industry Checkup: Measuring Progress in Improving Prior Authorization. American Medical Association. 2019.
        https://www.ama-assn.org/system/files/2019-03/prior-authsurvey.pdf.
        Accessed on February 2, 2020.
      15. Artificial Intelligence – What it is and Why it Matters. SAS Insights. 2020.
        https://www.sas.com/en_us/insights/analytics/what-is-artificial-intelligence.html.
        Accessed on February 1, 2020.
      16. Siwicki B. At RadNet, AI-fueled Prior Authorization Tech Shows Promise, Healthcare IT News, Global Edition. May 6, 2019. https://www.healthcareitnews.com/news/radnet-aifueled-prior-authorization-tech-99-accurate.
        Accessed on January 6, 2020.
      17. Napco’s iBridge Technology Named Top Innovation of 2014 by Security Sales & Integration Magazine – Recurring Revenue Model Makes iBridge a Top Choice for Security Dealers. January 13, 2015.
        http://investor.napcosecurity.com/2015-01-13-NAPCOs-iBridge-Technology-Named-Top-Innovation-of-2014-by-Security-Sales-Integration-Magazine.
        Accessed on February 3, 2020.
      18. Integrating Prior Authorization Solution with Epic PMS While Protecting PHI at a Pennsylvania Hospital Group. Infinx Case Study. 2018. https://www.infinx.com/resourcecasestudy/integrating-preauthorization-solution-with-epic-pms-lt/.
        Accessed on February 2, 2020.
      19.  Implemented a Complete Overhaul of Revenue Cycle Management Program for Large Hospital-Owned Cardiology Clinic. Infinx/Enhanced Revenue Solutions Case Study. 2018.
        https://www.infinx.com/resource-casestudy/implemented-a-complete-overhaul-of-revenue-cycle-management-program-for-large-hospital-owned-cardiology-clinic/.
        Accessed January 12, 2020.
      20. Ibid. 9.
      21. *******Chhaltralia V. What Does the Future Hold for Artificial Intelligence? Industry Analysis and Graphic, AI Business. March 22, 2018. https://aibusiness.com/industrygraphic-artificial-intelligence/.
        Accessed on February 2, 2020.
      22. Maximize Hospital Revenue with a Holistic Insurance Discovery Strategy. January 7, 2019.
        https://revcycleintelligence.com/news/maximize-hospital-revenue-with-a-holisticinsurance-discovery-strategy.
        Accessed on January 20, 2020.
      23. How Using Insurance Discovery Can Significantly Improve A/R, Infinx Blob. January 23, 2020.
        https://www.infinx.com/blog/how-using-insurance-discovery-can-significantlyimprove-a-r/.
        Accessed on January 23, 2020.
      24. 2018 Survey of America’s Physicians: Practice Patterns and Perspectives. The Physicians Foundation, Empowering Physicians/Improving Healthcare. 2019.
        https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf.
        Accessed on January 30, 2020.
      25.  New Findings Confirm Predictions on Physician Shortage. Association for American Medical Colleges. April 23, 2019. https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage.
        Accessed on February 1, 2020.
      26. Reporting appropriate use criteria in claims for Medicare Patients. American Medical Association. August 17, 2020.
        https://www.ama-assn.org/practice-management/medicare/reporting-appropriate-use-criteria-claims-medicare-patients.
        Accessed on August 19, 2020.