Rocky Mountain Eye Center Improves Prior Authorization Denial Rate and Turn Around Time

The Challenge: The Crippling Cost of Traditional PAs

Rocky Mountain Eye Center, a leading provider of comprehensive eye care, was struggling with the high administrative and financial burden of securing prior authorizations (PAs) for critical, high-value eye injections. The traditional PA process was characterized by manual data collection, lengthy back-and-forth with payers, and inconsistent denial appeals, resulting in four major areas of loss:

1. Inefficiency and Delayed Care

• Long Cycles: The manual submission process led to unacceptably long PA approval times, delaying life-altering treatment for patients with conditions like Macular Degeneration and Diabetic Retinopathy.
• High Overhead: Significant administrative staff time was consumed by following up on submissions and chasing down necessary clinical documentation.

2. Financial Losses from Denials and Delays

When PAs were denied or significantly delayed, RMEC faced immediate, measurable revenue losses:

• Care Downgrades: Patients, due to delays or insurance pressures, were often switched from optimal treatments (like Eylea or Lucentis) to cheaper, less effective alternatives (like Avastin).
  • Financial Impact: Loss of $1,070 in profit per patient who moved to a cheaper treatment.
• Patient Drop-Offs: The frustration and delay of the PA process caused some patients to abandon treatment entirely or seek care elsewhere.
  • Financial Impact: Loss of $3,000 in profit per patient drop-off.
• Claims Write-Offs: Denials that were not successfully appealed resulted in uncompensated care.
  • Financial Impact: Loss of $5,000 per denied claim written off.

Pre-Manta Health Annual Financial Leakage: RMEC was losing an estimated $113 in profit per patient receiving an eye injection at the practice if you average out the total losses above across all injection patients.

‍

The Solution: Manta Health's AI-Powered Prior Authorization

RMEC partnered with Manta Health to deploy its end-to-end AI Prior Authorization solution, focusing specifically on high-volume eye injection PAs. The goal was to remove human touch points, speed up approvals, and ensure a near-perfect submission and appeal rate.

Key Features Deployed:

• Auto-Approval Optimization: The AI engine standardized and optimized every submission package to automatically meet payer-specific criteria, driving a high rate of initial, touchless approvals.
• AI Denial Determination: For any initial denials, the Manta Health platform immediately identified the exact reason for the denial and determined the optimal appeal strategy.
• Automated Appeal Generation: The platform automatically generated all necessary appeal documentation, including a highly detailed Letter of Medical Necessity (LOMN) and updated clinical records, reducing the appeal process from weeks to days.

The Results: Speed, Autonomy, and Significant Revenue Recovery

Manta Health helped RMEC achieve immediate and dramatic improvements across all key performance indicators (KPIs).

Pilot KPI Performance

‍

Financial Impact Summary

By leveraging Manta Health, RMEC saw a 71% financial recovery on the challenged areas.

Annual Financial Leakage & Recovery by Category:

• Administrative Burden: 65% decrease in labor costs from doing PAs in house to using Manta.
• Care Downgrades due to denials (Switching to Avastin): 81% reduction in care downgrades
• Patient Drop-Offs Due to Denials: 75% decrease in patient drop off
• Claims Write-Offs: 80% reduction in PA related claims drop offs