How AI + Automation Optimizes Prior Authorizations for Orthopedic Practices

By Infinx
September 24, 2019

Today’s orthopedic practices are struggling with overworked staff members suffocating under the burdensome task of a seemingly endless number of manual insurance verifications and prior authorizations. This is a time for bold solutions—by implementing artificial intelligence (AI) and machine learning through automation, orthopedic practices can streamline insurance verifications and prior authorizations for real-time decision making when managing the patient access process.

Orthopedic Practices Struggle with Prior Authorizations

Over the past several years, orthopedic practices have seen a massive uptick in prior authorization denials—in some cases, as much as 300 percent. For years, ortho administrators have countered the rise in volume by hiring additional staff, but some problems cannot be solved with additional workforce alone. Manual processes like those necessary to determine a prior authorization for an ortho procedure are neither effective nor built to scale.

In addition to an increasing number of procedures requiring an authorization, ortho practices across the country face rising issues with meeting clinical requirements due to lack of documentation from referring physicians and constant changes to insurance payer policies and guidelines. Additionally, the appeals process ties up valuable resources with faxing and making telephone calls to follow up on approvals.

These factors cause delays in authorization leading to patient rescheduling and attrition as well as creating unwarranted financial risk due to missed prior authorizations and denials. Patients are forced to wait for urgently requested procedures, tests, or medications, and up to 35 percent ultimately abandon care completely.

A Bold Solution for Prior Authorization and Insurance Verification

With the introduction of AI-assisted automation and machine learning, systems that were once time and personnel intensive now become background, allowing the ortho team to focus on providing the best possible patient experience. Ortho practices can leverage AI to analyze patient insurance verification data and provide deep insight into their prior authorization requirements, potentially saving valuable time, resources, and money when scheduling procedures.

The cutting-edge machine learning algorithms baked into today’s Prior Authorization Software result in an ever-smarter, more efficient product, while also bringing the capability to be integrated into any EMR/EHR or practice management system through an API or HL7 integration. While this type of software will accurately identify authorization requirements based on complex criteria in real-time, it is also supported by prior authorization specialists to support manual emergent cases, clinical submissions, or interpreting handwritten notes on a report, resulting in a full end-to-end solution to your prior authorization and insurance verification workflow.

Today’s prior authorization solutions bring innovative, scalable patient access and revenue cycle management solutions for not only orthopedic practices but also for other healthcare specialties and hospitals as well. Combining intelligent, cloud-based software driven by artificial intelligence and automation, with exception handling by certified prior authorization and billing specialists, orthopedic practices can preserve and capture more revenue, enabling them to shift focus from burdensome administrative details to billable patient care.

Schedule a demo today and learn how you can maximize your orthopedic revenue through automated prior authorizations.

About the Author

Infinx

Infinx

Infinx provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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