How Hospital Radiology Departments Use Artificial Intelligence for Insurance Pre-certifications

By Infinx
May 28, 2019

It has become far too costly in the changing healthcare payment lifecycle to process prior authorizations manually. According to the 2018 Index Annual Report from the Council for Affordable Quality Healthcare (CAQH), only 12% of hospitals and providers have adopted an automated pre-certification process. Continuing to manage radiology pre-certifications, in the same way, is no longer viable.

Recertification requirements mandated by insurance payers continues to be a heavily-criticized endeavor–unnecessarily expensive, burdensome, and contrary to outstanding care delivery and an enhanced patient experience. As an oft-quoted “Health Affairs” article estimates, the annual cost to the healthcare industry is between $23 billion – $31 billion, possibly more.

The Case for Artificial Intelligence for Insurance Pre-Certifications

The American College of Radiology’s position is that pre-certification should not be allowed to hinder patient care, but that’s easier said than done. Hospital radiology departments have historically found themselves at a distinct disadvantage. This is because combined billing practices leave the pre-certification responsibility with the radiologist’s patient access group, forcing the hospital RCM team to sit second chair on reimbursement and collections.

This lack of efficiency, due to multiple and stratified players, has recently required a shift in responsibilities from the referring provider to the hospital, where a significant portion of the financial incentive lies. By using prior authorization software with artificial intelligence (AI) and predictive analytics, hospitals can expect their same-day appointments approved within four hours and emergency or STAT approvals in as little as 20 minutes.

Conquering Payer Rules

Utilizing robotic automation software with AI and machine learning ensures a system that’s entirely up-to-date and current on payer criteria, rules, and guidelines. This significantly lessens the risk of denied or rejected claims. The corresponding RCM workflow team then no longer needs to use resources on researching, gleaning, and disseminating information to workflow participants—often well after requirements take effect.

Additionally, prior authorization software is seamlessly integrated with each payer’s utilization department and selected Medical Benefit Management (MBM) broker so that the pre-certification process does not get bogged down with middle-man regulations and excess diversions. With AI-supported software, these ever-changing relationships can be tracked, and claims redirected in real-time.

Efficient Medical Records Extraction

When assessing the efficiencies brought by automation, one of the primary benefits of utilizing AI software is the dramatically accelerated extraction of pertinent medical information from the integrated EHR. Error reduction is realized through a variety of ways, including less manual rekeying and reduced misinterpretation from non-clinical staff members.

With routine tasks being automated, vital patient access staff can be redeployed to higher level endeavors that enhance the patient experience; a must in the coming years.

AI and Real-Time Workflow Automation

With robotic process automation, information sharing accelerates. Most pre-certifications are authorized and received within a small window, allowing the patient to be scheduled for their visit with an assurance that their obligations have been addressed with the payer.

For those pre-certifications requiring further monitoring, automated status-checking optimizes approval time through an established channel with the insurance payer. As outliers are further identified, those pre-certifications can be managed by exception through a team of highly trained specialists that respond quickly delivering resolution on behalf of over 99% of patients.

When addressing financial viability in today’s healthcare market, hospitals and radiology groups around the country are looking to gain actionable insights into financial systems and areas impacting the healthcare payment lifecycle. With most hospitals handling patient access and RCM for a variety of different departments including radiology, only 10-20% have dedicated authorizations leadership.

The time for a dedicated patient access effort is here. AI-enhanced Prior Authorization Software, as offered by Infinx, brings a comprehensive patient access program into play. Your hospital-based radiology program provides excellent patient care–let’s make sure you get the maximum reimbursement for the work accomplished.

Contact Infinx today to improve your radiology pre-certification process.

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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