Radiology is among the top three medical specialties with the highest number of services that require prior authorization. Payers request prior authorizations for 91% of radiology services.
Prior authorizations are a particular struggle for those in radiology’s most recent subspecialty: interventional radiology. Because these surgeons must make important decisions only once the surgery is started, they have to submit prior authorizations for dozens of procedures.
Getting clearance for all gives them the flexibility in the moment to select the procedures most likely to achieve the best patient outcome. Still, getting all of those prior authorizations done ahead of time takes work and thorough knowledge.
Our client, a New Jersey center with three board-certified interventional radiologists, found they were leaking revenue due to prior authorization errors and even failure to obtain prior authorizations in the first place. The practice, which also includes a team of interventional nurses, technologists, and administrative professionals, offers on-site CT-, MRI-, and ultrasound-guided treatments to diagnose, biopsy, and treat issues in a non-medical setting. They specialize in embolization, a procedure where the radiologist injects substances directly into an artery to block or reduce the blood flow to a tumor, essentially starving it.
An Inexperienced Vendor And Overburdened Practice Staff
While staff and surgeons understood they needed to get clearance on many of their procedures ahead of time, they had no concrete strategy for selecting the specific code groupings. Extraneous codes led to denials.
This interventional radiology practice initially had one staff member handling prior authorizations. Staying on top of the groups of procedures that could occur in each surgery as well as the current changes to guidelines for over a dozen payers is beyond the capabilities of any one individual. The practice hired a vendor to provide prior authorization guidance and support.
Unfortunately, it turned out that this vendor was not familiar with the codes and procedure code groupings involved in interventional radiology procedures — a relatively new subspecialty of radiology. Their errors on top of their late submissions due to inadequate staffing led to more denials.
The inability to secure prior authorization approvals, in turn, slowed scheduling — the bread and butter of any interventional radiology practice. Overhead and labor costs stay the same whether the schedule is full or spotty. Practice leaders knew getting more patients scheduled was key to their solving their problems.
A Confusing Vendor Portal Undermines Staff Buy-In
On top of frustrations surrounding prior authorizations and scheduling, staff found this vendor’s portal confusing and time-consuming to navigate. They remained as frustrated as when they were submitting prior authorizations without the vendor. The fact that the two parties never worked out a streamlined workflow added to the confusion. Staff had to keep up with prior authorization updates themselves and add in new payer-requested information or correct that information. These steps slowed scheduling and limited patient volume.
Specific Interventional Radiology Experience Make A Difference
When this client found us at an RBMA conference in early 2022, they had a better idea of what they wanted and what could go wrong with a third party. Weary of problems with their past vendor, staff had told their director of clinical services that they never wanted to use another vendor again. The director, however, is a believer in efficiency and the LEAN protocol and pushed them to try again.
She explained their issues to our representatives and got a demo of our prior authorization solution. She saw right away that our platform was far simpler and more robust and helpful than the previous vendor’s.
When she explained that inaccurate coding groupings were causing inordinate denials, we shared robust results we achieved with a larger interventional radiology practice. We assured her we would use the CPT codes and procedure groupings proven to work with various payers like we did for the other interventional radiology group. She was impressed that several of our team had deep clinical experience.
Our Pilot Program Demonstrates Highly Reliable Prior Authorization Submission And Follow-Up
The client was excited to embark on our pilot program. We agreed that our common goal was to get prior authorizations submitted in a timely and accurate way to lower denials and speed scheduling. We also committed to helping them develop a streamlined workflow for their staff to prevent delays.
With our solution, the client manually enters case details via our portal. Our solution guides them through the prior authorization process, ensuring they complete all steps and upload all necessary documents. It automatically submits the prior authorization to the payer in many cases. In complex cases, however, our interventional radiology prior authorization specialists work with the payer and the practice on what’s needed to get the prior authorization approved.
During onboarding, the client’s customer success manager demonstrated how to use the portal and the prompts that ensure all details are included. While weekly meetings were standard, our CSM was available at any time and able to resolve issues quickly. Well aware of the urgency behind interventional radiology prior authorizations, our team responds to any emails the client sends within 10 minutes. Issues take three days or fewer to resolve.
The Practice Thrives With A Complete Solution
With the power of both automation and specialists, the client can be sure all prior authorizations are addressed. Unlike our two-way approach, solutions that depend only on automation send a portion of prior authorizations back to the practice staff for them to work out with the payer. That time-intensive process involves staff confusion, long phone calls and research time, and additional staffing requirements.
The practice appreciated the freedom to talk to a person whenever necessary. Should a prior authorization seem stalled, their customer success manager calls the payer to help resolve the issue. Our experience dealing with specific interventional radiology issues brings hassle-reducing clarity for all parties.
Increasing Approvals With A Smooth Prior Authorization Process
Within weeks of signing the contract, we were processing hundreds of the client’s prior authorizations. Staff commented on how much easier their patient access process was. The director commented that staff was no longer “freaking out” about prior authorizations and scheduling, and the work environment as a whole improved.
By three months, their prior authorizations denials rate dropped to below 1%, an all-time low for the practice. Before our partnership, just 25% of the practice’s prior authorizations won approval, but our assistance brought that figure up to 39%.
Turnaround time has dropped significantly, too. With the coding more accurate and payer guidelines followed to the letter, peer-to-peer conferences have fallen off drastically. Prior authorizations are being approved more quickly, while patient care and confidence in the practice’s physicians and operations have improved.
Faster, more consistent approvals has helped this practice achieve their primary goal: more patients on the schedule. With more procedures being completed, revenue has also improved.
An Easy-To-Use Solution Pleases Staff
While treating more patients more often is the ultimate goal, partnership with us also brings operational perks. Staff has found data entry and case location far easier with our solution than with their initial vendor’s. The freedom to look at and interpret pending cases allows staff to update patients and doctors quickly. Staff appreciates how the solution’s red exclamation points and green check marks make entering data and documentation intuitive.
Today, this interventional radiology practice needs just one staff member to handle prior authorizations. They characterize their work with us as “life-changing!”
If you are looking to achieve similar results at your organization, contact us at www.infinx.com/request-a-demo.
As an interventional radiology practice, you’re supposed to submit prior authorizations for a dozen or more procedures before surgery even begins. But sometimes, listing too many results in denials. What’s a surgeon to do? See how one New Jersey interventional radiology center used a tech-enabled prior authorization solution that includes a team with deep knowledge in the specialty to raise their approval rates.
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