Large Southwestern Imaging Group Overcame Prior Authorization And Eligibility Verification Obstacles With AI And Automation

During the pandemic, a prominent imaging group in Texas continued to thrive, providing full-service outpatient diagnostic imaging and interventional radiology services across 40 facilities. However, the group faced challenges in keeping up with the demand for eligibility verification and prior authorizations. There were challenges with the increasing volume of STAT, same day prior authorizations, and walk-in appointments previously managed by scheduling and prior authorization teams.

 

Lagging Prior Authorizations Leading To Rescheduled Patients And Lost Appointments

This created challenges within the organization including:

• Keeping an appointment without obtaining an authorization (leading to possible claims issues)
• Reschedule the patient because an authorization was not obtained in a timely manner
• Obtaining the authorization

Losing appointments and having to reschedule patients was leading to decreased patient access and decreased patient satisfaction. These obstacles were also a risk to the fiscal bottom line of an organization.

 

Infinx’s Prior Authorization Solution Successfully Automates Process

After extensive discussions with Infinx, they decided to move forward with our prior authorization module of our Patient Access Plus platform. The trial began with processing all authorizations for the group on selected insurance payers. The company was impressed with the solution’s functionality and eventually added on more prior authorizations and payers to their process.

Patient Access Plus now processes 90–95% of the company’s authorizations, which is approximately thirteen thousand (13,000) authorizations per month across all facilities. This includes codes for CT scan of abdomen and pelvis with contrast (CPT 74177), MRI of the spinal canal (CPT 72148), MRI of the brain (CPT 70553), Fluoroscopy (CPT 77002), and ultrasound of the abdomen (CPT 76700), among many others.

 

Machine Learning And RPA Used To Streamline Prior Authorizations

Patient Access Plus uses artificial intelligence (AI) to determine if an authorization is necessary with a database of national, regional, and local payer rules. When needed, it uses payer integrations and robotic process automation (RPA) to rapidly submit claims, including provider details, patient information, and other necessary tests and diagnostic information.

Automation is also used to do continual status checks until a claim is approved and alerts practice staff when additional documentation or a peer review is needed. Exceptions are handled by our experienced specialists, minimizing the need for any manual intervention by the clinic’s staff.

 

Partnership Expands To Include Eligibility Verifications And Benefit Checks

While celebrating the prior authorization success, it was also found there were efficiencies needed with eligibility and benefit verification, and patient pay estimates. This prompted the need to consider a new solution. Over a period of years, the confidence and trust level elevated so the organization grew interested in Patient Access Plus’ eligibility & benefit and patient pay estimation modules. After building out a bidirectional integration with their internal medical records system, we began to perform eligibility verification and enhanced benefit checks along with patient pay estimates for all of the prior authorization cases.

Before the patient comes in for their visit, the front office staff verifies eligibility, benefits, and patient pay estimates. This information is key to ensure the patient know what to expect when arriving to their appointment. The information also enables the staff to assist the patient with navigation of their care. Upfront collections have increased. The outcome of incorporating this solution has increased patient satisfaction and also increased confidence of front office staff. There is much less confusion upon arrival for care.

 

Imaging Patient Access Further Streamlined With Help Of Document Processing Services

The radiology group also adopted our document processing solution for their incoming faxes. Physicians referring patients to the imaging center for services send the referral via fax. Errors at that point would delay turn-around times for prior authorizations.

Receiving those referral documents and utilizing our solution to correct errors by entering the right ICD-10 codes, CPT codes, and NPIs among other important data points sped up their prior authorization process.

 

Claim Scrubbing Leads To More Reimbursements

Due to the success of our patient access services, the imaging group also opted to use our services for claims scrubbing. We review and help correct claim errors before they get to the final claim process. Any errors can lead to a significant and direct revenue impact.

 

The Making Of A Successful Patient Access Collaboration

We started our relationship processing a small volume of prior authorizations. A trusting partnership was nurtured by our ability to consistently meet and exceed the radiology group’s internal quality metrics.

Currently, we conduct eligibility and insurance verifications, patient pay estimates, document management processing, and claims editing for all of their 40 locations.

Up to 85% of procedures and up to 99% of imaging prior authorizations are processed with our tech-enabled approach. Approximately 13,000 prior authorizations, and 18,000 eligibility verification and patient pay estimations are processed monthly. Claim scrubbing helped them ensure claims get paid the first time around. All services are processed with over a 98% adherence to our agreed upon turn-around-times.

Our partnership has enabled a strong pre-service financial clearance process for this imaging group, supporting a high patient satisfaction and healthy revenue recovery across their 40 locations.

 

Infinx Is A Trusted Partner

This client has rewarded our hard work with a net promoter score of 9 / 10.

If you are looking to achieve similar results at your organization, contact us at www.infinx.com/request-a-demo.