The client struggled to obtain prior authorization from insurance companies for procedures and medications, which is a significant administrative burden for physician practices. The process can be slow, and complex, and require extensive documentation, leading to patient care delays and frustration for physicians and staff.

• Struggled to seamlessly integrate various data sources, such as electronic health records (EHR), insurance databases, and prior authorization systems, ensuring that all relevant patient information was accessible and up to date.
• Complications in navigating complex and varied insurance policies, eligibility criteria, and coverage rules.
• Failed to ensure the accuracy and consistency of patient data & errors in data entry or discrepancies in patient records lead to incorrect eligibility checks, resulting in delays or denials.
• Challenges in customizing workflows and needs & ensuring that the solution was scalable to accommodate future growth and changes in healthcare practices.

HexaCorp implemented the below solutions that can integrate with insurance rules engines and automate the prior authorization process.

• Automated Eligibility Checks: Implemented system that automatically verifies patient insurance eligibility and coverage for the specific service when scheduling a procedure or prescribing medication.
• Rule-Based Automation: The system pre-populates prior authorization forms based on pre-defined rules and patient data, reducing manual data entry and errors.
• Integrated Documentation: The system pulls relevant medical history and supporting documentation from the EHR, eliminating the need for separate document collection.
• Real-Time Status Tracking: Provide physicians and staff with a real-time dashboard to track the status of submitted authorization requests, eliminating the need for follow-up phone calls.
• Denial Management: The system analyzes denials and identifies common reasons for rejection. It can generate reports with actionable insights to help physicians adjust their documentation approach and improve approval rates.