CASE STUDY

Eliminated Costly Prior Authorization Delays At Top U.S. Hospital With AI And Automation

The Background

One of the largest and most respected hospitals in the country contacted Infinx after they had run into problems with a patient access vendor in South America. The hospital was perpetually backlogged. It had to reschedule and turn patients away resulting in lost revenue and underutilized equipment. Overwhelmed and frustrated by costly payor delays and denials, the hospital sought a new, definitive solution to chronic prior authorization process inefficiencies and administrative issues, which had been adversely affecting both its patients and physicians for years. They needed a solution that could bring efficiency to the hospital’s utilization management while improving patient satisfaction and revenue.

Processing prior authorization requirements are complicated and labor-intensive. As the only solution in the market that leverages both artificial intelligence (AI) and human intelligence, Infinx guaranteed the hospital that its Patient Access Software solution would authorize every procedure before the appointment occurred, eliminating time-consuming efforts to chase down money after the fact. Additionally, Infinx offered unbeatable price points and experience migrating data from existing, problematic vendors.

20 hrs

Are spent at medical practices per week on tedious and time-consuming prior authorization activities that prevent tending to patient care

92%

Of physicians say that prior authorization programs have a negative impact on patient clinical outcomes, according to a 2018 AMA physician survey

The Technology

Our Infinx Patient Access platform helped the hospital get ahead of the revenue cycle problem by quickly authorizing and confirming that every procedure rendered could be billed with near certainty to its accuracy and propensity to collect. The solution is built on Infinx’s proprietary technology platform, Infinx Prior Authorization Software (IPA), which uses AI to automates repeated tasks with workflow optimizations. Exceptions are handled by prior authorization and billing specialists.

Thanks to seamless integration with the hospital’s existing EMR software, the platform was deployed with little disruption to the hospital’s day-to-day operations. We guaranteed strong IT security standards and the overall satisfaction of the hospital’s complex structure of internal stakeholders. Infinx also provided the flexibility of its team of healthcare prior authorization specialists when cases of exception processing required a manual touch.

Planning and Implementation

Our team mapped the hospital’s process and aligned its own process to create a best practice workflow. Next, we studied the hospital’s specific payer nuances and the hospital’s policies of how to handle payer questions. Then, we examined the clinic’s workflow for obtaining additional information for a patient. Once the implementation had been completed, we provided world-class customer support to handle issues, upgrades, and maintenance.

Optimized for Scale with Rapid TAT and Impeccable Accuracy

  • Designed for Scale: Infinx conducted 84,000 prior authorizations in six months. During this time, the prior authorization count nearly doubled from 9,500 to 17,500 prior authorizations per month.
  • Impeccably Accurate: Infinx conducted 20,152 audits over six months on the prior authorizations performed to measure the accuracy of the solution, and maintained a 99.5% rate of accuracy.
  • Continually Optimized: Infinx’s quality group conducted audits that allowed our client to track the agreed-upon metrics so, that our process continued to optimize.
  • Rapid TAT and STAT: For standard jobs, the next day and forward, Infinx initiated the request with the payers within 24 hours. For same-day jobs, appointments of same-day minimum four hours out, Infinx obtained a final determination within four hours. For STAT jobs, appointments within four hours of receipt, Infinx obtained a final determination within 30 minutes.

Confidential, Secure, HIPPA Compliant & Medical Necessity

It is standard practice for Infinx to maintain full HIPAA compliance, in both technical security and handling of patient information (PHI). Such standards have been a hallmark of our Infinx Patient Acess platform, and our prior authorization team:

  • Fully Encrypted: All PHI stored via iBridge were fully encrypted, per HIPAA guidelines, and stored on Amazon Web Services S3 cloud servers, at secured locations, providing SOC2 compliance documentation.
  • Completely Secure: Patient data was never stored longer than necessary, with regular archiving and purging. All files were password-protected and accesscontrolled, as necessary.
  • HIPAA Compliant: Prior authorization team members were proficient in HIPAAcompliant standards and protocols, via formal training and periodic reviews. Medical necessity was always observed and followed.
  • Regularly Audited: New software updates were thoroughly reviewed and tested for airtight data security, while all technical infrastructure and procedures were regularly audited throughout the year.
  • Private and Confidential: The customer’s privacy and confidentiality were 100 percent assured. Industry-standard intrusion detection, up-to-date firewalls. In addition, Infinx Implemented all HIPAA standards and regulations.

The Results

98% ACCURACY = PEACE OF MIND

  • 95%
    Overall successful authorization rate
  • 100%
    Compliance to all payer guidelines, protocols
  • >99%
    Error-free audits on all documentation
  • 100%
    SLA compliance to STATs, same day and standard appointments
  • 1000+
    Prior authorizations completed daily
  • 100%
    Compliance to HIPAA standards

Let’s Optimize Your RCM Workflow

Schedule a call with our team to learn how our solution can help optimize your revenue cycle.

      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.