CASE STUDY

Integrating a Prior Authorization Solution with EPIC While Protecting PHI at a Pennsylvania Hospital Group

Infinx has served one of Pennsylvania’s largest hospital systems, who had sought an innovative prior authorization solution which could significantly reduce costly payer delays and denials, which too often frustrated both patients and physicians.

After an evaluation process among several options for revamping their systemwide prior authorization operations, Infinx proved to be the strongest choice.

The solution needed to deliver an enhanced prior authorization workflow while providing seamless integration of their existing practice management software (PMS), EPIC. Strong IT security standards were also necessary, as well as overall satisfaction of a complex structure of internal stakeholders. These essential requirements were filled using our Infinx Prior Authorization Software, a cloud-based solution, with exception handling by our prior authorization specialists.

HIPAA Compliant Infinx Prior Authorization Software

Initially, we addressed the customer’s concerns in regards to maintaining full HIPAA compliance, in both technical security and handling of patient protected health information (PHI). Such standards have been a hallmark of our software and team:

  • All PHI stored via the Infinx Prior Authorization Software are fully encrypted, per HIPAA guidelines, and stored on Amazon Web Services S3 cloud servers, at secured locations, providing SOC 2 compliance documentation.
  • Patient data is never stored longer than necessary, with regular archiving and purging.
  • All files are password-protected and access-controlled, as necessary.
  • Prior authorization specialists are proficient in HIPAA-compliant standards and protocols, via formal training and periodic reviews.
  • New software updates are thoroughly reviewed and tested for airtight data security, while all technical infrastructure and procedures are regularly audited throughout the year.

Successful Two-way HL7 Integration with EPIC

After demonstrating full HIPAA compliance, our next step was configuring our software to interface with the customer’s existing EPIC PMS. EPIC’s HL7 interface differs from other common PMS systems, which use ADT or ORM messages to share patient scheduling information. Our interface engineering team, experienced in multiple HL7 platforms, tackled this issue and configured the REF message type to support this two-way interaction.

Our engineers were able to ensure that our Prior Authorization Software could handle all types of incoming message scenarios. We worked with the hospital interface team to define business rules, flags and relevant data transmission conditions, developing a list of over 100 possible scenarios, each tested during a week-long exercise. This identified a number of ambiguous triggers, which were fine tuned in advance of a smooth transition.

The engineering team next designed an REF-compatible AUT segment which could automatically transmit all authorization-related information back to EPIC, reflecting interim statuses and final outcomes during the process of preauthorization. Testing was conducted to ensure data was flowing back to EPIC at all points.

Establishing Payer Contact Protocols

This regional hospital system included a broad span of physician groups and practices. For purposes of operational consistency, they preferred us to represent ourselves as calling on behalf of the provider imaging facility when contacting payers. This presented multiple challenges of how to properly initiate prior authorization calls, provide necessary clinical information, follow-up and escalate cases to deliver the most expedient processing possible.

After extensively researching requirements of benefit managers and payors, our team developed a comprehensive, fully-compliant methodology for universal payor communications. By the formal launch of service, we were fully prepared to successfully process prior authorizations with virtually any payer based in the United States.

Matching Our Resources To The Customer

The larger size and scope of this customer’s radiology operations also required flexibility of our prior authorization resources to successfully meet this new volume of business. Expanding our team required a systematic, sequential onboarding process to ensure every team member was consistently prepared to implement the technological and operation protocols we’d developed for this customer. This resulted in a clean, organized and speedy roll-out with few notable “growing pains”.

Infinx Delivers Successful Results

  • Due to our technical and subject matter experience and flexibility, we provided an advanced, technology-led prior authorization solution custom-tailored to the customer’s stringent security and compliance requirements.
  • Our company was able to adapt, expand and rapidly bring new teams up-to-speed via a custom-tailored onboarding program.

RESULTS BY THE NUMBERS

  • Overall >95%
    successful authorization rate
  • 100%
    SLA compliance to TATs on stat, same day and standard appointments
  • 99%
    error-free audits on all documentation
  • 100%
    compliance to all payer guidelines, protocols

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