CASE STUDY

How an East Coast Medical Imaging Center Increased Daily Revenue by $750-1000 Per Day by Automating Their Prior Authorization Workflow

Client Profile

The client is an East Coast medical imaging center with one of the most successful outpatient radiology practices in the United States. It is also one of the largest single-center imaging centers with three MRIs in one location. They specialize in providing full major modality scans, specifically CT, PET, MRI, and Nuclear Medicine.

The Challenge

The Radiology Group Was Experiencing an Overwhelming Volume of Prior Authorization Demands

Roughly 70% of the referring providers, the group worked with had asked the radiology group to obtain the necessary prior authorizations from the payers directly. The problem was that certain payers were only allowing imaging centers to start the authorization process, but not complete it—other payers don’t allow imaging centers to process the prior authorizations at all. Unfortunately, the client was watching as their competitors sidestepped these rules and continued to process the authorizations themselves. Thousands of dollars per week in patient revenue were at risk. The imaging center needed a way to follow the rules while also remaining competitive.

Additionally, about 30% of the client’s daily patients needed expedited authorizations. Acquiring the necessary approvals from the insurance companies via phone could take up to an hour per authorization—a logistical nightmare for the small authorizations team in place. The client could not counter the rise in volume by simply hiring additional staff. If they wanted to retain patients and also maintain good working relationships with the referring physicians, they needed a solution that could receive authorizations quickly and accurately.

The Solution

A Prior Authorization Solution that is Ready to Scale

Faced with a high-volume of prior authorizations and a small staff, the imaging group prioritized a solution that could offer total automation of the prior authorization workflow, an interface that was easy for their staff to learn, and cloud-based access so that it could be accessed by any computer. They also needed a legitimate way—payer approved— to process authorizations, and the Infinix solution was the answer.

The proprietary Prior Authorization Software for imaging centers evaluated each of their procedures to determine if a prior authorization was required. The software then initiated the cases electronically that did require an authorization to the specific payer or benefits manager. Once a case was initiated, the software provided the radiology group with an authorization reference number and
continuously followed up with payers by using automation that provided real-time updates and notifications.

The solution was completely integrated with the client’s RIS system. This allowed the provider to work within their system and not have to log into another webbased system to submit their prior authorization requests. This created a low maintenance and low touch experience for the customer and also saved the provider staff a lot of time and effort in manually entering case information into a web portal.

At full utilization, the Infinx Prior Authorization Software provides an unprecedented ability to scale as authorization volumes increase and when a network expands to include new geographies.

In addition, Infinx’s prior authorization specialists were available to manually handle any request, in the event of a complex scenario or if the payer did not support electronic submissions.

The Results

Infinx’s Prior Authorization Solution Levels the Playing Field Within 2 Months

It only took four weeks to go live and two months to see results, which leveled the playing field with their competition. By utilizing Infinx’s Prior Authorization Software, the radiology group has realized a number of tangible benefits:

  • Reduced insurance verification and benefits processing time
  • Eliminated the need for another full-time employee to process the authorizations
  • Faster turnaround times for patient authorizations and scheduling
  • Significantly reduced manual and burdensome administrative tasks
  • Strengthened relationships with referring physicians and medical practices

Future Forecast

While today Infinx processes 200+ imaging scans per month for this radiology group, within a year’s time they anticipate that number of prior authorizations increasing significantly to as many as 800 to 1,000 imaging scans per month.

The group is now poised and excited to deploy the full utilization of Infinx’s Prior Authorization Software, which includes the proprietary Authorization Determination Engine—a rules-based engine that leverages machine learning to authorize requirements in real-time and optimizes the radiology group’s workflow and patient retention efforts. With full utilization of the Prior Authorization Software, the group believes it will be able to handle the increased volume efficiently and effectively.

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.