In ophthalmology, prior authorizations are particularly troublesome. Payers insist that ophthalmologists take patients through tiered medications or step therapy before qualifying for the most effective medication. Since each step may require prior authorization, this process can take months and result in loss of vision. For this reason, efficient prior authorization workflows are crucial for ophthalmologists.
One multi-location ophthalmology practice with over 50 referring providers was determined to get its patients the timely care they needed by improving both the speed and accuracy of their prior authorization process. They also resolved to stop the revenue leaks occurring in their eligibility verification process.
Eligibility Verification And Prior Authorization Bottlenecks Drop Patient Volume
This ophthalmology practice faced two issues. First, they accumulated a backlog of prior authorizations for patients, delaying scheduling and care. Second, they couldn’t consistently verify patient eligibility and benefits. Both tasks were handled manually by front-office staff. When prior authorizations took over one month to turn around, patients became frustrated, impacting the group’s reputation. Without prior authorization approvals, front office staff couldn’t schedule patients. These issuues led to a drop in patient volume and revenues.
At times, front office staff struggled to check on prior authorizations and eligibility while scheduled patients sat waiting. These last-minute checks resulted in patients going home when eligibility couldn’t be verified or prior authorizations were denied.
The group also lost significant revenues after completing unverified services. Too frequently—particularly in acute cases—ophthalmologists ended up seeing patients before eligibility and benefits had even been established. That left the front office chasing the patient for payment after services were rendered. These accounts went to write-offs and the loss of revenue hampered the group’s potential to add new equipment and expand.
With the widespread healthcare staffing shortage, the group couldn’t find sufficient skilled staff to handle these issues. They began exploring whether a partner could assist with prior authorizations, preferably one that was cost-effective.
Patient Access Plus Chosen To Streamline Eligibility And Prior Authorizations
The ophthalmology clinic found us through their search online. During the vetting process, they learned that through our partnership with digital enrollment provider PX Technology, we had partnered with many ophthalmology clinics to speed up prior authorization turnarounds and improve accuracy.
In addition to our expertise in ophthalmology prior authorizations, they appreciated that we had deep experience with Horizon Blue Cross/Blue Shield and the other predominant providers in the New Jersey area. Our eligibility verification services, too, would help ensure more consistent payments coming in.
Assured that we could assist with their prior authorization and eligibility verification processes, they embarked on a pilot program of our Patient Access Plus solution.
Tech + Specialists Streamline Eligibility And Prior Authorizations
The client established their onboarding program by assigning us 160 surgical prior authorizations and eligibility verifications weekly from one location, that had only one supporting staff member. The streamlined process took less than two weeks.
Once patient information is entered into our system, the first step is our eligibility and benefits verification module which:
- Automatically runs eligibility checks days before scheduled visits, streamlining their process and significantly reducing their workload.
- Eliminates eligibility errors that result in denials later on
- Doesn’t return blank or partially complete cases due to our eligibility specialists who augment the automation to ensure complete coverage
When necessary, the same patient details are used to initiate a prior authorization case, without any repeated data entry. Using AI and automation, our prior authorization engine:
- Automatically determines if the payer even requires prior authorization for the procedure
- Submits prior authorization directly to payer portals
- Provides prior authorization analytics that help optimize workflows
Our certified prior authorization specialists take over when exceptions occur and alert practice staff only when additional documentation is necessary.
Patient Access Workload And Turnarounds Significantly Reduced, Allowing Faster Surgical Scheduling
Impressed with the improved turnaround times and accuracy of the prior authorizations and eligibility verifications allocated to us, they opted to expand our involvement to all cases group-wide—4,000 per month. We are currently building an electronic integration from our product to their EMR to facilitate this.
Their manual patient access workload has been reduced significantly, while maintaining a high degree of accuracy and keeping costs low. Turnaround times for eligibility and prior authorizations have been reduced, allowing them to see surgical patients faster. We’ve also helped staff understand prior authorization and documentation requirements better which has helped streamline their workflow going forward.
Another advantage they’ve enjoyed is a reduction in their data entry tasks. They only enter a patient’s data once to enable both prior authorizations and eligibility verification. With the integration upcoming, their manual workload will be reduced further. The practice is eagerly awaiting the rollout of our product organization-wide.
If you are looking to achieve similar results at your organization, contact us at www.infinx.com/request-a-demo.
Is your ophthalmology practice behind in scheduling patients due to eligibility verifications, benefits checks, and prior authorization delays? See how one group increased patient volume and satisfaction by using a tech-enabled solution to get patients verified and scheduled faster.