In the fight between health insurers and patients, I have seen that healthcare providers are caught squarely in the middle, which can be a costly position.

The provider’s battle begins before the patient enters the medical facility. Studies show that providers can spend as many as 20 hours a week getting preauthorization for their patients. It is a lengthy process that can cost each provider an average of $83,000 annually, and that figure can increase when you factor in lost productivity.

The battle often 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.

As VP of Product for Infinx, I have been working on solving these issues through an artificial intelligence (AI) driven software solution that covers 100% of prior authorizations because it is backed up with exception handling by certified prior authorization and billing specialists.

Helps Determine If Prior Authorization Is Required Or Not

For all procedures that are performed, their software evaluates to determine if prior authorization is required. As insurers keep changing their policies, the machine learning algorithms have the ability to learn and adapt to these changes. (This Prior Authorization Determination Engine feature is a new product update that just launched and will be available to demo at their booth at HIMSS19 trade show in Orlando in February 2019).

This determination is provided at time of scheduling of the procedure allowing providers to schedule these patients at the earliest to improve patient experience for these cases.

The solution can also help identify if the prior authorization request requires a clinical review and also accurately predict the turnaround time for that specific case to allow clients to the best possible schedule for their patients.

Electronically Submits Prior Authorization Requests With Exception Handling By Specialists

If it is determined if a given procedure requires prior authorization, the provider can electronically submit the request to all payers using a single web portal or integration with Infinx, reducing the need to make multiple calls or send faxes to different insurance companies. No need to log into multiple payer portals individually.

The authorization requests can be electronically transmitted using integration or robotic automation and Infinx prior authorization specialists are on hand who can make manual submissions in complex scenarios or if payer does not support electronic submissions.

Automatic Status Updates To Ensure Procedure Gets Scheduled On Time

Once these authorization requests are submitted, the software provides clients with an authorization reference number and will constantly follow-up with payers using automation that provides real time updates as soon as a payer make approves them.

The solution continuously evaluates the follow-up against the scheduled date of service and turnaround risk to intelligently hand-off to our prior authorization specialists if follow-up with the payer is necessary to ensure an authorization before the service is rendered.

Alleviates Administrative Burden, Patient Scheduling Anxiety & Financial Risk

In summary, Infinx’s AI-driven Prior Authorization Software eliminates a healthcare provider’s administrative burden of obtaining prior authorizations while providing insights that help them improve the patient procedure scheduling experience without any taking any financial risks of performing procedures without insurance approval.