Prior Authorization for Medical Imaging: Are You Completely Prepared to Get Paid Quickly Post-COVID?

By David Byrd
June 9, 2020

Like a whirlwind, COVID-19 seemed to appear out of nowhere and completely disrupted the global community. Economies are stressed, industries are experiencing unprecedented changes, and governments are trying to manage it all.

With astounding speed, hospitals and healthcare workers rallied to absorb the influx of critically ill patients. At the same time, governmental agencies and private health insurers waived fees, changed care delivery models and instituted new coding structures.

Simultaneously, hospitals and other providers quickly postponed nonemergent or elective procedures as patients stayed away in droves, accessing clinicians through new telehealth alternatives or foregoing care altogether.

Bogged down with backlogs

Today, with many states lifting or easing stay-at-home orders—and with everyone anxious to get back to some semblance of normalcy—healthcare providers face an enormous backlog of postponed care. Few are flush with the resources needed to chip away at their mountainous workloads.

What’s more, for many radiology groups, the pent-up demand could be further bottlenecked by payers’ requirements for prior authorization (PA).

This looming difficulty is daunting enough for the entire specialty that the American College of Radiology has formally written to the five largest insurance companies (United Healthcare, Aetna, CIGNA Anthem and Health Care Services Corp). The influential association believes in the appropriateness of a temporary PA suspension—one that would continue for three months after the present public-health emergency subsides.

Additionally, the Centers for Medicare and Medicaid Services (CMS) has issued guidance to private Medicare Advantage providers, encouraging them to forego PA requirements at least through the pandemic.

Exponentially unmanageable

To balance the growing list of available imaging options with existing levels of contractual obligation, payers are using PAs to manage both physician behaviors and patient expectations.

Meanwhile, even in less hectic times, obtaining a PA continues to vex many if not most radiology groups. The process is labor-intensive and time-consuming. Often staff must diverge from patient-care duties to spend hours on PA tracking and follow-up.

From the initial determination, there are multiple risks for delays and denials, creating a healthcare reimbursement conundrum that is growing exponentially unmanageable. This, in turn, creates accumulating problems for insurance payers who are trying to contain costs and ensure medically sound and appropriate patient care is being delivered.

Prior Authorization burdens

To balance the growing list of imaging choices available with existing levels of contractual obligation, insurance payers are using PAs to manage physician behaviors and patient expectations. Obtaining a PA continues to be an ongoing struggle for most radiology groups today. The process is labor-intensive and time-consuming, often requiring hours of constant follow-up by staff that takes time away from patient care.

From the initial determination, there are multiple risks for delays and denials, creating a healthcare reimbursement conundrum that is growing exponentially. This, in turn, creates growing problems for insurance payers who are trying to contain costs and ensure medically sound and appropriate patient care is being delivered.

Nearly all branches of medicine are feeling the pinch of declining reimbursement, which is only accelerated by the Protecting Access to Medicare Act (PAMA), and the continued proliferation of high-deductible health plans, which saddle patients with more out-of-pocket costs than many can readily afford.

This effect was clearly shown in the American Medical Association’s 2018 Prior Authorization Physician Survey. The AMA found 91% of respondents reported care delays, and 28% said the often-delayed process led to a patient having a serious adverse event (death, hospitalization or a life-threatening event).

A solvable problem

As is clear for anyone mindful of U.S. healthcare’s Quadruple Aim—improving patient experience and population health while reducing costs and supporting care teams—there’s got to be a better way.

The good news is that there is a better way.

Thanks to technological advances in predictive analytics, machine learning and other iterations of artificial intelligence (AI), prior authorizations can now be managed in real-time with little need for human attention.

That’s right. Software has been developed to more or less run itself within any healthcare provider’s EHR/EMR or RIS, operating through a fully integrated, HIPAA-compliant interface that utilizes massive insurance clearinghouses for precise, accurate processing.

AI completes the pass

At Infinx Healthcare, we have had a hand in applying AI and automation to the challenge of streamlining clinical workflows and tackling time-consuming, repetitive tasks—all with an eye on turning PA problems into operational opportunities.

Today’s Infinx Prior Authorization Software leverages cloud computing to let AI-driven automation integrate bi-directionally with a practice’s EHR/EMR or RIS and revenue cycle management (RCM) systems.

Here’s how it works. When a patient’s order arrives, the electronic toolkit identifies which exams or treatments require a PA. Next the software collects details on involved providers and facilities, relevant patient demographics and ordered clinical procedures. With these data points gathered, the software automatically submits a PA request to the payer. It also flags orders with any sort of deviation from the norm so these can be reviewed by a PA specialist.

The comprehensiveness of this approach explains why we confidently call our product a complete PA coverage solution.

In fact, it even goes beyond that. There are thousands of insurance groups and plans, each with its own unique guidelines. To keep up, Infinx Prior Authorization Software uses machine learning capabilities to constantly update insurance information and clearinghouse parameters. It’s always up to date on whether or not a PA is required for any given order, and it “knows” the way to the appropriate payer portal.

The results speak for themselves. Prior authorization requests that used to take several hours to several days—and sometimes weeks—can now be initiated in near real-time with a determination accuracy rate north of 98%.

Brawny data fortress

Despite the ubiquity of cloud computing, some still worry about privacy and security when it comes to storing health data in the cloud. For this reason, we designed Infinx Prior Authorization Software as a seamless and scalable PA solution that uses Health Level 7 (HL7) or Application Program Interface (API) based bi-directional integration. It’s compatible with all leading EHR/EMR and RIS systems.

The software guards all patient health information in layers of security compliant with Electronic Data Interchange (EDI) standards, storing data in the cloud using 64-bit and 256-bit encryption. HIPAA compliance is 100% assured.

Endless learning

One of machine learning’s best features is its ability to learn as it operates—and to share what it’s learning as it goes.

In the case of Infinx Prior Authorization Software, this translates to tracking PAs using real-time analytics, continuously following up on these findings and, upon completion, reporting back to the scheduling department.

When appeals are needed, the practice can define how to handle them, and the system can seamlessly execute their protocol. This is a prime example of smart automation eliminating the need for staff to spend countless hours holding the phone or faxing information to the many different insurance payers.

Similarly, human experts augmented by AI can step in to accommodate unexpected changes—procedure level, service level, demographics—as they’re reported. This kind of information can be critical to the PA process, so the Infinx Prior Authorization Software keeps the appropriate staff members in the loop while instantly retransmitting information to the affected payer.

And speaking of staff, AI can’t do everything. In every case, maintaining a support team of highly trained specialists is required. AI must be supplemented with human intelligence to handle emergent or complex requests and exceptions. It’s through a team of trained specialists that a radiology practice is ensured complete coverage of their PA workflow.

Getting real about revenue

Without a doubt, radiology practices are under severe pressure from changes in fee schedules. And reduced reimbursement models are being implemented across U.S. healthcare. At the same time, good care outcomes increasingly rely on more and better diagnostic tools and treatment procedures.

It’s a scenario placing radiology practices and imaging centers in a financial vice grip—one that’s only going to squeeze tighter as time goes by.

This reality was recently fleshed out by the widely respected Council for Affordable Quality Healthcare. In its 2019 CAQH Index, the organization estimated the current cost to process a prior authorization at around $14.24 (manual) vs. $1.93 (electronic). The potential industrywide savings averaged $12.31 for each occurrence.

Granted, the CAQH methodology uses a lot of variables—salary costs, insurance company variants, procedure/test mix—that can vary from region to region. Still, these potential cost savings are eye-opening.

Take charge of change

Surveying the shifting fiscal landscape, we see a healthcare economy in flux and under the most stringent constraints in terms of reimbursement reduction, increasing paperwork and administrative headaches. Among other side effects, this source of pressure is causing clinician and provider burnout to spike at unprecedented rates.

From where we sit today, it appears clear that every able individual working in, around or near healthcare needs to pitch in to relieve the load of healthcare workers and those who support them. At Infinx we truly believe that taking a proactive stance by automating the PA process can greatly aid radiology practices without delay.

Further, taking this step can prepare any and every practice—completely—for whatever opportunities and challenges take shape down the road.

David Byrd is VP of Growth and Strategy at Infinx Healthcare. For a limited time, Infinx is inviting radiology practices to try its Prior Authorization Software free for two months. For details or to set up a demo, visit www.infinx.com or inquire at sales@infinx.com.

About the Author

Infinx
Infinx Healthcare 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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