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Authorizations. Get answers in minutes, not days.


According to a report from MGMA during 2016 and 2017, payer prior authorizations requirements have:

Authorizations


Authpal's cloud-based tool automates the authorization process, allowing procedures to be scheduled the same or next day.

Authpal automates the prior authorization process, making it faster and easier to receive confirmation from the health plan. Instead of waiting days and following up via phone, fax, and email, your staff can determine almost immediately whether an authorization is required, submit it, and receive confirmation. When authorizations are automated, your staff can focus on high value-activities like patient care, satisfaction and scheduling.


36% of denials are due to authorization or patient registration issues.

Authpal offers built-in validations to prevent denials while automatically checking for authorization status, allocate work based on payer rules and provide an automatic proof of authorization number and valid dates in PDF form. By automating the authorization process, patients will be less frustrated over adminsitrative denials.


Three-step authorization process


There are three key steps to obtaining an authorization: determining if one is needed, submitting it if it is, and obtaining the authorization from the payer. Availity Authorizations addresses all three.

  • Step 1: Determination
    • When the pre-certification specialist schedules the procedure in the EHR/RIS, an HL7 feed is automatically sent to Availity, where the CPT-specific authorization is checked against both our robust knowledgebase and the payer site. If an authorization is not required, the confirmation is sent back to the EHR/RIS. Otherwise, the process moves to submission.
  • Step 2: Submission
    • In approximately 20 percent of cases, an authorization can be submitted without additional clinical input. In those cases, Availity Authorizations first checks the payer site to see if the authorization has been submitted by the referring physician. If not, the authorization is submitted and moves to the next stage in the process.

      When an authorization requires clinical intervention, Availity Authorizations places the case in pending status, so the pre-certification staff know it needs attention. The pre-certification specialist then opens the case and Availity Authorizations automatically connects to the correct payer and pre-populates much of the information, so the specialist can quickly input the clinical information and submit.
  • Step 3: Retrieval
    • Once the authorization has been submitted, Availity Authorizations continues to ping the payer behind the scenes until it receives notification. Then it returns the authorization approval number, valid dates, and an archived screen capture via HL7 to the EHR/RIS.


Benefits

  • Reduce cost by redeploying staff members and decreasing denials.
  • Improve yield by increasing operational efficiency and scheduling capacity.
  • Increase patient and referring providers’ satisfaction.
  • Streamline staff workflow by eliminating manual processes.




Patient Access - Eligibility, Benefits, and Claims Management

The Patient Access solution gives access to real-time patient data, allowing your front-desk staff to accurately resolve patient collections at or before the point of service. Our solution streamlines the patient collections workflow process from the moment a patient checks-in to the time that the claim is paid.


Patient Access Flow Chart

Streamline claims submission and get real-time access to multiple payers at no cost to your facility


Availity’s multi-payer portal gives your facility secure access to multiple health plans, allowing you to check eligibility and benefits, obtain real-time authorizations, check referrals, and more—all at no cost to you. The Availity Web Portal—as it’s known to users—features a streamlined interface, so you only have to log in once to conduct transactions with your contracted payers.



The Patient Access solution includes the following:

  • Customized scripting delivers real-time, responsive communication prompts that guide staff through payment scenarios.
    • Contract calculator estimates the appropriate patient financial responsibility at the point of service, based on the facility's contractual terms with payers.
  • The propensity to pay combines demographic data with household income, net worth, and other financial indicators to predict capacity to pay.
    • Financial assistance uses federal poverty guidelines in conjunction with the patient's income information to determine the need for financial assistance.
  • Insurance verification and medical necessity deliver up-to-date benefit coverage information and cost estimates so you can collect patient financial responsibility.
    • Payment processing allows you to accept payments allows you to accept payments via cash, check, and credit or debit card.
  • Address and identity verification allow you to verify critical billing information, using only the patient's name and address.
  • Quality and reporting help you make better business decisions and identify process and policy improvements.



Features

  • Eligibility and benefits inquiries
  • Real-time authorizations and referrals
  • Patient cost estimators
  • Professional and facility claims



Benefits

  • Improve productivity by using one website to access multiple payers.
  • No cost to providers as the health plans covers the cost.
  • Fewer denials as the result of having real-time access to updated patient and payer information.




Case Study #1

Challenge

A well established, multi-state diagnosticimaging facility (X-Ray, Nuclear Medicine, PET/CT, CT, MRI, Ultrasound, and Mammography) does 35,000 exams a year of which 8,500 require authorization. Each authorization takes an estiamted 35 minutes per authorization.

Solution

Automated prior authorizations

Results

For 80% of the cases, it took less than 15 seconds to obtain eligibility and 2 minutes to receive authorization. The patient's financial responsibility was more accurate because of connectivity directly to the Payers, instead of using web portals

  • Reduced number of employees needed for eligibility verification and authorizations.
  • Decreased the amount of employee turnover and the costs associated with recruiting , hiring, and training a new employee.
  • Annual Savings - $120,000
  • Five-Year Savings - $500,000

Case Study #2

Challenge

A large chain of imaging centers centers faced with hiring more employees to keep up with an increasing authorization workload.

Solution

Automated prior authorizations

Results

  • Time to obtain prior authorizations reduced from days to minutes.
  • Patients' wait times reduced, and cases scheduled same or next day.
  • Pre-certifications staff's time on the phone down from 60% to less than 10%.
  • Increased productivity at the front desk. Staff available for other tasks.
  • Zero denials due to prior authorizations.


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