Introduction
We received a request from a clinic to improve their E&V and prior authorization process
Challenges
When IDS received the data, we reviewed the policy and structure for the process. In our review we identified the below challenges
- We found a lag in communication between front end scheduling & E&V staff.
- There was avoidable delay in submission of claims as the approval of charge was delayed.
- The clinic was not receiving authorization for the rendered services within the timeframe.
- The access to the web portals was limited which was leading to excessive time consumption on phone calls.
- The appointment scheduling process was not efficient, causing huge patient dissatisfaction and low turnaround & provider time utilization.
Our Solution
When IDS received the project we did this deep dive analysis, the IDS team prepare a comprehensive plan to improve the process and standardize it for the clinic:
Insurance Verification and Prior Auth
- We reviewed the procedures being performed along with the payer mix to analysis the payer guidelines and form a payer plan wise covered / non covered procedures guidelines sheet.
- With this team was more efficient to do the benefit check, resulting accurate patient responsibility determination- leading to improved patient collections.
- We prepared a chart for the frequent payer’s clinic handle with their phone number, mailing address, documentation required, payer templates and prior auth guidelines.
- We setup the documentation checklist and SOP’s for all payers. With this team was more aware about the procedures required auth & what documentation should be submitted to get them approved.
Appointment scheduling
- We provided solution to automate patient reminder, appointment scheduler which improved the patient experience.
- We provided the improved mechanism to upload the patient information and charges which resulting in the reduction of the lag.
Payer Portals Setup
- We reviewed the opportunity to reduce the manual work and insurance call time for the payer who provide web services.
- We setup the clinic for approval processes for the charges to reduce the number of claims awaiting approval for being submitted to insurance carriers.
- We setup the Payer portals so we can review the benefits & PA requirement without calling the payer.
Result
With the implementation of the correct practices, we were able to improve the collections, patient experience and were able to reduce the claim submission lag and the drop in front end registration & PA denials.
- We see an improvement in the overall insurance and patient collections.
- We have increased the average monthly overall collection from $87k to $113k in period of March 2021 to March 2023
- Also, we have reduced the average denial from 973 to 589 claims for the same period.