Digitizing Prior Authorization for Better Patient Outcomes
Client Profile
A global medical technology leader that designs and manufactures life-saving cardiovascular and endovascular products such as pacemakers, defibrillators, and remote patient monitoring systems. The company's mission is to enhance and extend the lives of patients with heart and blood vessel conditions through advanced innovation and patient-centric care.
Problem or Challenge
The prior authorization process, a critical step in patient treatment, was a major bottleneck in the company’s healthcare delivery and revenue cycle operations.
- Patients often had multiple policies with varying coverage rules, leading to confusion and delayed approvals.
- Patients were frequently unaware of non-covered treatments until they received post-treatment denial notifications, resulting in unexpected costs.
- Hospitals manually gathered medical data from multiple departments, each needing to match specific formats required by various insurers.
- Reliance on paper forms or scanned PDFs led to processing delays, impacting treatment timelines and revenue collection.
Solutions
To streamline and digitize the prior authorization process, Rialtes developed a Salesforce-based solution using Salesforce Health Cloud that connected hospitals, healthcare providers, patients, and insurers within a unified digital workflow.
Unified Digital Platform
: Consolidated insurance details, ICD codes, and treatment information into a single interface accessible to hospitals and care teams.Medical Input from Physicians
: Enabled doctors to directly enter required clinical data, ensuring accuracy and completeness.Digital Patient Consent
: Integrated electronic consent collection, ensuring transparency and compliance with patient authorization requirements.Standardized Submissions
: Automated the transmission of complete medical records using industry-standard formats (HL7 and FHIR), compliant with HIPAA regulations.Condition-Aware UI
: The user interface dynamically adjusts based on the medical condition, guiding users through all required steps to maximize authorization success.
Benefits
- Streamlined communication between hospitals, providers, patients, and insurers through a single source of truth.
- Improved accuracy and completeness of submissions reduced insurance denials by 30%, minimizing delays in patient care and revenue loss.
- Transitioning from paper to digital submissions cuts prior authorization approval times by up to 50%, improving overall care delivery speed.
- Greater transparency reduced surprise billing and enabled more confident treatment planning.
- Hospital administrative workload for prior authorization processing decreased by 35%, freeing up staff to focus on patient care.
