For cardiologists, getting patients access to the most appropriate treatment too often stands at odds with the financial interests of payers. All physicians endure monumental frustration when delays and denials involved in prior authorizations lead to patient harm, an outcome that occurs too frequently.
In a 2021 American Medical Association study, 18 percent of physicians report that prior authorization delays have led to “life-threatening” events, and 34 percent say that prior authorization issues have led to “serious adverse events” for a patient in their care.
Vein and vascular vein prior authorizations are some of the most burdensome in medicine. Because vein treatments can be considered cosmetic, payers seek documented proof that more conservative treatments like ablation therapy have occurred. They may also look for doppler or duplex ultrasound studies assessing the anatomy. Payers insist on the existence of many cardiovascular issues like whether significant reflux at the saphenofemoral or saphenopopliteal junction exists before granting an authorization.
Analytics Diagnose Sources of Revenue Leakage
To break its prior authorization bottleneck, improve billing coding accuracy, and reduce denials, this group sought a partner with proven expertise in cardiology billing and prior authorization. After another Texas provider referred us to this practice, we sat down with management to review the shortcomings in their current system and examine where we could improve revenues, collections, staff workload, and processes.
We requested 12 months of their charges and the associated collections that came in on those charges, as well as data on their accounts receivable. Our revenue cycle analytics team uploaded this data to our cloud-based Revenue Insights software.
Results in hand, we showed practice leaders what they were collecting and cross-referenced that with what Medicare and BlueCross/BlueShield typically pay. This process helped us find where most coding and prior authorization errors were occurring. It also revealed just how much revenue they were missing out on.
Our analytics helped display show significant denials due to inaccurate coding and documentation. It became clear that the group’s current billing company had serious labor issues and sorely lacked cardiology coding expertise. The practice owner, a thoracic surgeon, recognized that his current billing company was failing his organization.
Infinx Chosen To Overhaul Prior Authorizations, Coding, And RCM
Eager to turnaround his practice’s financial performance, and recognizing our expertise in cardiology revenue cycle services, the pratice’s owner selected us to improve revenue by addressing prior authorization, coding, and other RCM challenges.
Our highly skilled coding experts are updated on government regulations and coding changes. They’ve learned what works through decades of personal experience. Our coders keep certifications valid by completing ongoing education every year, and our team is led by a MedAxiom member.
Automated Prior Authorizations Reduce Workload by 70%
Once the relevant patient information is entered into our web based prior authorization portal, our AI-based authorization determination engine analyzes them based on its national database of payer rules. With a degree of accuracy, we can predict whether an authorizations is needed.
If an authorization is required, our solution initiates it with a payer. Our operations agents frequently check status and step in when complex cases arise. When a payer requests a peer review or additional clinical information, we alert the client immediately. Once the authorization is approved, details appear on the client’s EMR.
The group’s new automated prior authorization workflow is easier to use and standardized across the five clinic locations. It has led to a 70% reduction in staff manual workload.
Coding Workflow Overhauled To Minimize Denials
On the collections end, we worked with the practice leaders to address outstanding A/R and establish RCM process improvements to massively improve reimbursements.
Once our analysis revealed where coding errors were triggering denials, we put our team to work using their coding expertise to submit claims accurately. While carrying out this work, we were able to provide feedback to improve coding, documentation, and charge capture going forward.
While transitioning from one partner to another can cause some complications, we worked closely with the cardiology practice to ensure they were paid for all care delivered despite the transition. We delivered a monthly report in month one, and continue to provide information on how collections are faring against how much was getting reimbursed before we came on board.
A 1,000% increase in monthly collections
By the seventh month of our partnership, the group’s collections had increased drastically from $90,000 to $900,000 per month due to a full overhaul of their revenue cycle management processes. This increase has been upheld for the last 17 months.
Management and staff are less stressed, and processes are far more efficient.Their prior authorization and denial management workload has diminished considerably. Best of all, getting their revenue cycle in order has helped them to expand.
Additional Revenue Stream from OBL Addition
Increased reimbursements have provided this group with the capital to capture additional opportunities like the build of an office-based lab (OBL). A recently acquired PET scanner allows physicians to detect serious heart arrhythmias without the delays involved in scheduling with an outside imaging center. Open heart surgery, of course, still takes place in a hospital. The group also added a procedure room with heart catheterization and diagnostic equipment usually only available in major tertiary care hospitals.
For nearly two years now, the group has awarded us with a 10/10 net promoter score (NPS). They have been able to turnaround their practice’s financial outlook and build the capital needed to expand their business.