Salesforce Health Cloud, Prior Authorization

Client Profile

A global medical technology company that develops and manufactures innovative products used by doctors to diagnose, treat, and monitor people with cardiovascular and endovascular conditions. This includes pacemakers, defibrillators for regulating heart rhythm and remote monitoring systems for patients with implanted devices. Their main goal is to improve the lives of people diagnosed with heart and blood vessel diseases.

Problem or Challenge

The prior authorization process for medical treatments was complex and time-consuming for the MedTech company.

Patients often have multiple insurance plans with varying coverage details. They are often unaware of coverage limitations until after treatment is denied, leading to surprise bills.

Hospitals struggle with extensive paperwork, including collecting medical data from various departments and submitting it in formats specific to each insurance provider.

Traditional paper-based or scanned submissions lead to delays in insurance approvals, impacting patient care.

Solutions

Rialtes developed a Salesforce-based solution to address these challenges and improve the prior authorization process for the MedTech company.

Patient insurance information, treatment details, and relevant ICD codes were integrated into a single digital platform.

We enabled doctors to add necessary medical data directly to the platform.

Clear and transparent patient consent is obtained electronically within the platform now.

Complete information from all departments is now submitted electronically to insurance providers in industry-standard formats (HL7 and FHIR) ensuring HIPAA compliance.

The UI adapts to the specific medical condition, which guides users through the required information needed for successful authorization.

Benefits

The centralized platform allows communication and data exchange between all parties that are involved.

Complete and accurate information leads to fewer denials and resubmissions.

Digital submissions and standardized formats accelerate insurance approvals.

Increased transparency and quicker approvals lead to a more positive patient experience.

Faster approvals enable quicker reimbursements to hospitals and the MedTech company.