How CFOs Can Measure the Success of Prior Authorization and Denials Management Solutions

By Infinx
July 9, 2019

In what has truly been the swiftest adoption of technology for the business of healthcare, hospital systems are recognizing that predictive analytics and machine learning are moving the healthcare payment lifecycle ahead by light-years.  Whether examining the prior authorization process or denials management, solutions are available that can reduce errors, predict necessity, and even examine and determine a patient’s propensity to pay.

However, in a recent Black Book CFO Survey, health system CFOs and VPs of finance assessed their patient access and revenue cycle management processes and reported that only 25% were fully automated and digitized.  Even when over 85% of finance executives expected substantial return on investment (ROI), they were resisting movement away from the traditional accounting, reporting, and compliance focus towards a technology-based strategy.

Technology-Based Prior Authorization & Denials Management

To assert themselves as true business partners and steer away from being viewed as the billing department responsible for collecting revenue and historical reporting, hospital finance executives must embrace the disrupting technology of Artificial Intelligence (AI) augmented by human expertise.  CFOs and VPs of finance are seeing their roles shift to include a strong focus on performance risk metrics and data analytics to influence technological shifts for their entire organization.

Tackling prior authorization and denials management impacts not only the bottom-line revenue by decreasing or eliminating complicated and labor-intensive manual processes but increases both patient and stakeholder satisfaction.

Let’s look at how these solutions disrupt the status quo in current hospital billing and collections practices and how you can measure their success.

Prior Authorization Done Right

Processing prior authorizations (PA), while necessary, is often ranked as the number one complication experienced by hospitals and providers alike.  It can be tedious, is often handled manually or with only partially automated systems, and can delay or stifle patient care. Implementing an augmented-intelligence patient access component for preauthorizations streamlines and mechanizes the most redundant pieces with 99% accuracy while outliers and emergency or STAT requests can be handled by highly-trained experts.

To measure the effectiveness of an AI-enhanced system, one only must observe the workflow to see the vast increases to accuracy and the reduction in staff time necessary to complete each PA:

  • Determining if an authorization is required—which visits can be handled as routine and which are going to require PA approval
  • Electronically submitting PA requests to the various payors through their individual submission portals—each with different processes and guidelines
  • Automated follow up with real-time status updates increases staff efficiency in patient scheduling
  • PAs are automatically updated in the system and tracked as to the number of visits approved, etc.
  • Outliers and exceptions, such as STAT referrals, can be processed by an expert team of specialists

Impacting Denials Management

Denials management erodes revenue and is often abandoned during the follow-up process due to mishandling and lack of understanding.  A full 5% of denials fail timely filing requirements. With that comes growing A/R inventory, aging claims, and write-offs that all impact your bottom-line revenue.

With AI-enhanced workflow automation and machine learning, data can be turned into actionable insights that encourage maximum recovery and can be assessed through:

  • Examining denial data and analytics to determine the best course of action
  • Prioritizing efforts and “next best action” to capture the maximum reimbursement
  • Executing and follow up to ensure payment
  • Forecasting collectible and expected amounts for future modeling
  • Discovering insurance and clearinghouse-related rejections to prevent future problems.

In today’s environment, hospitals and providers need to rise to meet the challenges exploring new ways to use technology to overcome obstacles.  With the demands of value-based reimbursement and with healthcare consumerism on the rise, hospital CFO’s and VP’s of finance are on the front line of implementing game-changing predictive analytics and AI-enhanced technology to sharpen results and hone reimbursement maximization.

Contact us to request a demo and see how to implement advanced technologies today.

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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