Surgery Scheduling Delays Resolved By Automating Prior Authorizations For Michigan Orthopedic Clinic

Our client is a moderately sized orthopedic surgery practice in Michigan operating in seven offices across the state for over two decades. They specialize in sports medicine, joint replacements, and spinal surgery and have expertise in various orthopedic subspecialties. They employ over ten orthopedic surgeons as well as several board-certified physician assistants.

While receiving a high volume of referrals for their surgical offerings, the orthopedic clinic was struggling to cope with the backlog of surgical and imaging prior authorizations due to a decrease in patient access staff. They were seeing extremely long turnaround times and having to reschedule surgeries due to a lack of timely authorizations. Reimbursements were also slowed down due to the lagging surgery schedule, which was causing cash flow challenges.

They explored multiple solutions, including 3rd party staff augmentation. But after a referral from the American Alliance of Orthopedic Executives (AAOE), the clinic decided it would be best to to bring in automation by implementing Infinx’s prior authorization solution.

During onboarding, we coordinated with the practice administrator and billers to implement our solution. Within a few weeks, our solution was fully incorporated with their current workflow so that the practice staff could confidently use it.

The practice built a strong working relationship with our customer success team, and was able to quickly and effectively resolve the patient access challenges as a result. The practice staff greatly appreciated our timely communication as well as our solution’s
accessibility and ease of use.

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

The dashboard on the left displays case information, along with the status of prior authorization claims.

RPA 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.

The practice soon found that our solution was able to save time, create a more efficient workflow and improve organization by centralizing all authorizations in one place for their team and providers. They were able to coordinate with our specialists to resolve challenges with particular cases as they came up. When claims were delayed or denied, they were able to hand them off to our team for troubleshooting and save hours on the phone with insurance companies.

Our prior authorization solution’s machine learning-based analytics module was able to create a greater degree of transparency into their authorization process. With the ability to visualize key metrics such as turnaround time, CPT code, and modality, they could rapidly identify roadblocks, such as which CPT codes were most commonly being denied authorization.

This analytics module provides insight into the solution’s performance by displaying KPIs. It also allows staff to build their own custom reports.

Our solution was able to create a streamlined prior authorization process with over 98% accuracy and a 70% decrease in workload. This reduced turnaround times and created a better workflow for authorization team members and providers, meaning the practice no longer had to reschedule surgeries due to their staffing shortage.

Patients are happy to receive their care faster, and the practice has seen increased approval rates. They can also collect revenue quicker with the improved efficiency of their scheduling process. The clinic knows that going forward, staffing challenges will no longer be an obstacle to their surgical scheduling and patient access process.