Optimized Orthopedics: Prior Authorization Process Workflow

By Infinx
March 14, 2019

So many procedures — and so many types of procedures. It’s no wonder orthopedic practices struggle to process such a large, diverse and ever-changing volume of prior authorizations every week. When authorization needs vary wildly from procedures and surgeries to physical therapy, imaging, rehab, medications, and injections, the corresponding patient-insurer friction can overheat the most efficient of organizations.

Before the patient even enters the facility, an orthopedics front office may have spent as many as 20 hours a week acquiring prior authorization for their patients. It’s a quagmire that is not limited to orthopedic practices, of course. All manners of U.S. practices lose as much as $83,000 annually, and that figure doesn’t even account for lost productivity.

The battle continues long after the patient has been seen. According to recent studies, a provider can lose more than 3% of patient revenue due to insurance company denials. Nearly a quarter of those denials are related to patient eligibility. While most denied claims can be recovered through the appeals process, the cost to appeal can be as high as $120 per claim.

Further complicating matters is the fact that many payers have recently updated their guidelines around orthopedic prior authorizations, which has caused significant confusion and a sudden demand for guidance.

Fortunately, Infinx has solved these issues for the orthopedic practice with an artificial intelligence-driven software solution that not only covers 100% of prior authorizations because it is backed up with exception handling by certified prior authorization and billing specialists but also learns and adapts to changes instituted by payers nationwide.

How to Speed Up Prior Authorizations

Inside Infinx’s Prior Authorization Software is the Prior Authorization Determination Engine, which Infinx launched at the HIMSS’19 conference in Orlando, Florida. This proprietary algorithm not only adapts to previously unpredictable changes, it learns from them.

It evaluates each orthopedic claim, and can instantly determine if a prior authorization is required, or not. With each evaluation it grows smarter and faster as it analyzes the ever-evolving insurance landscape. With every policy change, the engine grows smarter and faster.

It provides timely, increasingly accurate answers to pressing authorization questions, and can accurately predict the turnaround time for each specific case, optimizing and saving healthcare providers valuable time, resources and money when scheduling procedures.

Speeding up your prior authorizations doesn’t just mean a more satisfying patient experience, of course. It also means a significant boost to the orthopedic practice’s revenue. Infinx’s Prior Authorization Software eliminates much of the busy work that is prone to being bungled by human error. When an orthopedic procedure requires a prior authorization, an orthopedic practice can electronically submit their requests to all payers using a single platform, reducing the need to make multiple calls or sending faxes to different insurance companies. There’s no longer a need to log into multiple payer portals individually.

Navigating Changing Payer Guidelines

If you work at an orthopedic practice, you know that obtaining prior authorization for procedures such as MRIs, computed tomography, and at times, surgery has become more difficult over time. The good news is that Infinx understands payer guidelines better than any other prior authorization solution on the market. When major payers change their policies, Infinx pays particular attention to the policies that impact your orthopedic practice.

Plus, Infinx has industry-leading experience working with payers nationwide. This institutional knowledge translates to guideline fluency to get your orthopedic practice fast approvals and preserve more revenue through your payment lifecycle.

Centralized Scheduling Best Practices

Once these authorization requests are submitted, the software will continuously follow-up with payers and provide your practice with real-time notifications as soon as a payer makes any changes to a case. The Infinx Prior Authorization Software continuously evaluates each case, and will automatically submit to our prior authorization specialists if follow-up with the payer is necessary to ensure an authorization is completed before the patient’s scheduled appointment.

Infinx’s AI-driven Prior Authorization Software not only eliminates much of the administrative burden associated with prior authorizations, it also provides insights that help your orthopedic practice improve its patient procedure scheduling experience without taking additional financial risks by performing procedures without a prior authorization.

Schedule a demo today and learn how Infinx can maximize revenue in your orthopedic practice payment lifecycle.

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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