Case Study
Prior Authorization Issue

Client Overview

The client is a mid-sized specialty healthcare provider offering a range of physical, occupational, and speech therapy services. They were experiencing significant issues with claim denials due to missing authorizations.

Challenge

The primary challenge faced by the client was frequent claim denials because the required authorizations were not on file at the time of claim submission. This led to delays in reimbursement, increased administrative workload, and a negative impact on the overall revenue cycle.

Our Solution

Audit and Analysis

Conducted a detailed audit of the client’s current authorization and billing processes to identify gaps and areas for improvement.

Streamlined Authorization Process:

Established a standardized procedure for obtaining and documenting authorizations before services were rendered. This included setting up automated reminders and checklists to ensure no authorization was missed.

Enhanced Communication

Set up direct communication channels with insurance to facilitate quicker responses and resolve authorization issues.

Claims Resubmission

Assisted the client in resubmitting previously denied claims with the appropriate authorizations to recover lost revenue.

Protection Image

Results Achieved

Reduction in Denials

The rate of claim denials due to missing authorizations dropped by 90% within the first six months of implementing the new processes.

Improved Reimbursement Time:

The average time for claims to be processed and reimbursed was reduced by 40%, leading to improved cash flow.

Administrative Efficiency:

The administrative workload related to handling authorizations and resubmitting denied claims was significantly reduced, allowing staff to focus on other critical tasks.

Revenue Recovery:

Successfully recovered a substantial portion of previously denied claims by resubmitting them with the correct authorizations.

Reduction In Denials
0%
Improved Reimbursement Time
0%
Administrative Efficiency
0%
Revenue Recovery
0%

Conclusion

By implementing a robust authorization management system and enhancing the administrative staff’s skills, we dramatically reduced the incidence of claim denials due to missing authorizations. This resulted in faster reimbursements and improved overall efficiency for the client. Our tailored approach not only resolved the immediate issues but also established a sustainable process for managing authorizations, thereby securing the client’s revenue cycle and positioning them for long-term success.
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