CrosLinks

As aleading digital marketing company in the USA, CrosLinks  offers top-tier services that propel businesses to new heights. Our comprehensive solutions include SEO, PPC, content marketing, social media management, and email marketing. We focus on delivering measurable results and maximizing ROI for our clients.

As the best medical billing service company in the USA, CrosLinks  stands out with its commitment to accuracy, efficiency, and client satisfaction. Experience seamless revenue management solutions designed to optimize cash flow and reduce administrative burdens. Explore CrosLinks , a trusted medical billing company near you, offering local expertise and nationwide reach. Benefit from personalized service and proactive support tailored to meet your healthcare facility's billing needs.

Executive Summary:

CrosLinks, a solutions and services company, collaborated with a leading nationwide diagnostics laboratory in the United States to enhance the efficiency of medical transaction processes, particularly in insurance verification, patient engagement, prior authorization, and medical billing. The current inefficiencies in transaction processing are primarily due to complex billing procedures, insurance interactions, and varied patient demographics.
This case study focuses on improving the operational efficiency of the prior authorization filing process for genetic tests. It outlines strategic initiatives such as process consolidation, platform setup, and continuous monitoring to enhance throughput and ensure the timely completion of transactions. The analysis identifies key factors contributing to inefficiencies and proposes targeted steps to improve performance and ensure the successful completion of the prior authorization process.

Introduction:

XYZ Corp is a leading company in genetic testing, performing millions of tests annually in the fields of oncology, women’s health, and organ health. With a network of clinics and centralized testing centers across the United States, XYZ Corp directly engages with patients and healthcare providers to collect samples, perform tests, and manage billing with insurance companies.
Due to rapid growth, XYZ Corp has faced challenges in maintaining a high completion rate for approved authorization claims due to varying filing deadlines and stringent documentation requirements set by insurance providers.
This case study explores the root causes of these challenges and recommends solutions to streamline the prior authorization process.

Problem Statement:

XYZ Corp operates a billing model in which the company directly bills insurance providers on behalf of patients for completed genetic tests. The typical process involves:
1. Obtaining prior authorization from the insurance provider.
2. Collecting samples from patient and performing tests.
3. Submitting test results and generating bills for the tests.
4. Sending the bills to the insurance provider.
However, due to the nature of XYZ Corp’s operations, insurance interactions typically begin after tests are completed. Although insurance providers allow retroactive prior authorization requests, these must be filed within a specific time-frame. Missing this filing window results in claim denials and financial losses for XYZ Corp.
Key factors contributing to these issues include untimely filing, inaccurate patient information, improper documentation, and delayed follow-up with claims. The requirements and processes vary significantly across insurance providers, complicating the submission process and increasing the likelihood of missed filing deadlines.

Methodology:

The study involved collecting data from multiple insurance providers regarding the time and steps required to process prior authorization requests. Insurance providers were grouped based on test types, processing methods, and request types.
Standard processing templates were created, and these templates were analyzed against actual workflows to identify redundancies and ensure compliance with mandated steps.
Based on these findings, a comprehensive application system was developed to manage claims according to insurance-specific filing methodologies, parameters, rules and deadlines.

Solutions and Recommendations :

To address these issues, the following strategies were implemented:
• Application System Development: Introduced a system that integrates insurance-specific parameters, automates case assignments, and manages follow-up processes.
• Automated Document Retrieval: Developed automated document retrieval and assignment based on insurance requirements, ensuring that all medical necessity documents are included in submissions.
• Workflow-Based Processing: Created templates for processing claims tailored to each insurance provider, streamlining the workflow and reducing processing time.
• Shared Resource Pool: Established a cross-trained workforce capable of handling claims for all insurance providers, improving resource utilization and efficiency.