Northstar Medical Management Automates Surgical Pre-Certification, Streamlining Volume and Cutting Financial Risk

The Challenge: A Critical Bottleneck Threatening Surgical Volume

Northstar Medical Management oversees numerous surgical centers that handle thousands of procedures monthly. While surgical volume was high, the administrative process required to confirm payment and authorization was entirely manual, creating a massive, resource-draining bottleneck that exposed the organization to significant financial risk.

The primary struggles centered on two manual, highly variable processes:

1. PA Determination: The Plan-Procedure Maze

• Problem: For every procedure (from orthopedic to general surgery) and every patient's unique insurance plan, staff had to manually determine whether a Prior Authorization (PA) was required.
• The Cost: This meant a tremendous volume of phone calls to payers daily. Since PA rules are not standardized and change frequently based on the CPT code, diagnosis code, and specific plan, Northstar's staff spent countless hours on hold and researching payer portals, delaying the scheduling process and frustrating patients.

2. Benefits Analysis: Decoding Coverage

• Problem: After eligibility was confirmed, the team faced the complex task of predicting the patient’s financial responsibility. They had to manually analyze complex insurance plan documents, often in PDF form, to determine specific coverage details (deductibles, co-pays, out-of-pocket maximums, facility fees).
• The Cost: Inaccurate analysis led to patient financial surprise, increasing bad debt and pushing up claims denial rates due to misunderstandings about covered services.

The Operational Impact: Northstar's administrative efficiency was being choked. The manual, phone-intensive processes resulted in excessive staff labor, slow patient scheduling, high risk of claims denial, and a poor financial clearance experience for patients facing surgery.

The Solution: Intelligent Pre-Certification with MantaHealth AI

Northstar Medical Management deployed MantaHealth's AI platform to completely overhaul their pre-certification workflow, transforming it from a manual, phone-based chore into a scalable, automated system.

MantaHealth focused on creating a touchless financial clearance process by deploying two critical AI capabilities:

1. AI Prior Authorization (PA) Determination Engine

• How it Works: MantaHealth's engine uses continuously updated payer-specific rules and sophisticated logic to analyze the CPT code (procedure), ICD-10 code (diagnosis), and the patient's specific plan/product.
• The Result: The system instantly determines if a PA is required. If a PA is necessary, the system automatically initiates the submission using the correct documentation and channel, eliminating staff time spent researching requirements and making manual phone calls.

2. AI-Powered Benefits Analysis

• How it Works: The AI uses Natural Language Processing (NLP) to ingest and analyze unstructured benefits documents (EOCs, policy manuals, summary of benefits). It cross-references these details directly against the scheduled surgical procedure.
• The Result: The platform provides an accurate, automated cost-of-care estimate, outlining the exact coverage rules (e.g., “Facility fee is covered at 90% after the $5,000 deductible is met”), enabling clear financial counseling for the patient and drastically reducing bad debt risk.

The Results

Comparison of Pre-Surgical Processes (Before vs. After MantaHealth)

• PA Determination Time:
  • Pre-MantaHealth (Manual): 20–30 minutes per case (research/phone call)
  • Post-MantaHealth (AI-Powered): < 10 seconds (Automated logic check)
• Phone Call Volume (to Payers):
  • Pre-MantaHealth (Manual): Nearly every patient/surgery required a call
  • Post-MantaHealth (AI-Powered): Reduced by 93%
• Staff Time on Benefits Verification:
  • Pre-MantaHealth (Manual): Hours of manual document analysis
  • Post-MantaHealth (AI-Powered): Automated to an instant, auditable summary.
• Risk of Uncompensated Care (High Denial Risk):
  • Pre-MantaHealth (Manual): High due to eligibility/PA errors
  • Post-MantaHealth (AI-Powered): Significantly Reduced