Sample deliverable: Workflow automation
Automation design: prior-authorization intake
Fernmoor Physical Therapy. A three-clinic physical therapy practice handling about 180 insurance pre-approvals a month by hand.
Sample deliverable prepared for a fictional client. Names, figures, and findings are illustrative.
1Summary
Fernmoor Physical Therapy needs insurer pre-approval (prior authorization) before most new patients can start treatment. Today two front-desk staff handle about 180 requests a month by hand, across faxes, the health-records system, and payer websites. A decision takes 6 business days on average, and patients wait.
We propose an automation that reads incoming referrals, builds the request from data already in the health-records system, submits it to the insurer electronically, and tracks the response. Staff review only the cases the automation can't finish on its own.
- Requests per month
- 180
- Average time to a decision
- 6 to 2 days
- Staff hours per month
- 90 to 25
- Requests with no manual typing
- 85%
2How it works today
| Step | Who | Time |
|---|---|---|
| Referral arrives by fax | Front desk | 2 min |
| Patient and order typed into the health-records system | Front desk | 6 min |
| Insurer rules looked up on the payer website | Front desk | 5 min |
| Request filled in on the payer website or faxed | Front desk | 8 min |
| Follow-up calls until a decision arrives | Front desk | 6 min |
| Decision recorded and scheduler told | Front desk | 3 min |
That is about 30 minutes of staff time per request, roughly 90 hours a month, spread across days of waiting between steps.
3The automated flow
- Referral received Fax or electronic referral lands in a secure intake folder
- Referral read Patient, diagnosis, and order details extracted; unclear fields go to a staff review queue
- Health record matched Patient and order created or updated through the health-records system (HL7 and FHIR)
- Insurer rules checked Payer rules table decides whether a request is needed and what to attach
- Request submitted X12 278 request sent through the practice's clearinghouse
- Decision tracked X12 278 response read; approval recorded and the scheduler notified
Integration map
| System | Connection | What moves |
|---|---|---|
| Health-records system | HL7 v2 messages in, FHIR API for lookups and updates | Patient details, referral orders, authorization status |
| Clearinghouse | X12 278 request and response over SFTP | Authorization requests and decisions |
| Fax service | Secure fax API | Incoming referral documents |
| Staff alerts | Internal email | Notices to review a case (no patient details in the message) |
4Controls
The automation is designed for HIPAA requirements and runs inside Fernmoor's own cloud account, reachable only over the practice's VPN.
| Control | How it works |
|---|---|
| Audit log | Every view, change, and submission is recorded with who, what, and when, and kept 6 years |
| Access | Staff sign in with individual accounts; each role sees only what it needs |
| Encryption | All data encrypted in transit and at rest |
| Minimum necessary | Requests include only the fields the insurer requires |
| Vendors | Business associate agreements in place with every vendor that touches patient data |
5Expected results
Today
- About 30 minutes of staff time per request
- 6 business days to a decision on average
- Status lives in staff memory and sticky notes
- Missed follow-ups delay treatment
With the automation
- Staff handle only exceptions, about 1 in 7 requests
- About 2 business days to a decision
- Every request has a visible status and history
- Overdue requests are flagged automatically
Estimated staff time drops from about 90 to about 25 hours a month, which frees the front desk for patients at the counter and on the phone.
6Rollout and support
| Phase | Length | What happens |
|---|---|---|
| Shadow mode | 2 weeks | Automation runs alongside staff at one clinic; results compared, nothing submitted |
| First clinic live | 2 weeks | Automation submits requests at one clinic; staff review every exception |
| All clinics | 2 weeks | Rolled out to the remaining two clinics |
After launch, optional monthly support covers monitoring for failed submissions, updates when insurers change their rules, and fixes.