100% ROI in just 23 days. We Automated Eligibility Checks!

Project Scope

Pain Treatment Centers of America (PTCoA) is one of the largest fully comprehensive pain management practice networks in the U.S.A. They're operating in 13 clinics across Arkansas and Mississippi. 

They provide cutting-edge interventional pain treatments and advanced surgical services, their RCM team needs to ensure timely reimbursements and smooth administrative workflows.

Pain management is a high-volume & low-margin, as well as high-repetition & fast-burnout field. Reputation and Net Promoter Score are crucial here. 

Initially, PTCoA came to us with a very specific need – they asked us to address their most time-consuming RCM processes through AI-powered automation.

So we agreed.

Main Challenge | Eligibility Checks

Most pain management plans consist of multiple procedures.

Epidural injections, nerve blocks, follow–up visits, or therapy sessions…each of these requires precise eligibility verification.

Even minor errors, like outdated policy data, mid-month plan changes, or incorrect benefit types, meant that a whole chain of claims would later bounce back.

In pain management, eligibility checks are straightforward and repetitive, yet absolutely crucial.

PTCoA’s billing department was facing hundreds of small, repetitive claims daily. The process was fully manual and required constant human oversight. 

Their RCM specialists had to:

• Cross-check patient insurance details across multiple payer portals by hand,
• Confirm coverage and copayment eligibility for every visit or procedure,
• And manually transfer verified data between EHR and billing systems, since no integration existed between them.

With no technological solution in place, the team was essentially processing patients data by hand – from coverage check to data entry.

That meant 5–7 minutes per patient, multiplied by hundreds of daily visits.

A growing verification backlog, delayed claims, and a mounting administrative burden…

With rising patient volumes and expanding payer requirements, manual verification became a scalability bottleneck – costing PTCoA valuable hours every week.

That’s where we stepped in.

Solutions: 

Since the main goal was to save FTE hours, we started by mapping the entire eligibility verification workflow. After all, RCM automation doesn’t have to be one big leap – it can be approached in small, targeted steps that deliver fast results.

We spent a long time with PTCoA’s team to catch every step.

Pain management practices have their own operational rhythm – high visit frequency, small-ticket procedures, and multiple insurers per patient.

After several days of workshops, we had a complete picture of their eligibility workflow.

It quickly became clear that automated data exchange between PrognoCIS (EHR) and Trizetto (Billing Service) was the cure.

Eligibility Check Automation

Within a month, we deployed a fully automated eligibility verification process.

Each time a new appointment is created, the automation triggers instantly – confirming eligibility in real time before the visit.

When inactive coverage or missing IDs are detected, records are flagged for staff review, preventing downstream denials.

All verification results are timestamped, logged, and archived within a HIPAA-compliant environment, for maximum PHI security and full audit traceability. Moreover, the solution also integrates seamlessly with other PTCoA workflows already in use.

What used to be a chain of manual steps now runs silently in the background. 

Our automation swiftly:

• Logs into payer portals,
• Retrieves active policy data,
• Verifies coverage, copay, and deductible information,
• Writes verified data directly back to PrognoCIS.

To top that off, our data-exchange pipeline verifies patient coverage and calculates copayments continuously – all without human intervention. 

It’s worth noting that verified coverage information is instantly synced with TriZetto, ensuring pre-claim data stays consistent across systems.

How the Eligibility Check Automation Works? 

Here’s how it works:

1. Data Trigger: A new appointment is created in the EHR.
2. Portal Login: The Eligibility Checker logs into the relevant payer portals or API endpoints.
3. Verification: It extracts key insurance data – coverage, copay, deductible status, and policy dates.
4. Bad Coverage Flagging: Inactive or mismatched coverage is automatically flagged in the patient record for review.
5. EHR Update: Verified details are automatically written back into the patient record.
6. Notification: Staff receive alerts for exceptions or missing data.

Results: 

Automating eligibility verification gave PTCoA an instant efficiency boost across the entire RCM chain. 

Our automation overwatches eligibility checks 24/7, cutting down the processing time to 45 seconds each case – all without human supervision.

As a result:

• Check–ins were faster,
• Net Promoter Scores (NPS) improved,
• The volume of checks increased,
• RCM team unlocked full-time employee (FTE) capacity.

That’s the real power of solid AI automation in healthcare. 

On top of that, our eligibility automation combined with solutions like Denial Hunter, together achieved a 100% return on investment in 23 days, projecting $180,000 worth of savings after year one. 

In short: 

We solved the eligibility checks bottleneck.

With the success of the eligibility check automation, PTCoA continues to grow.

Their road plan for automations now covers lab orders, price comparison, write–offs, and patient communication.

Together, these solutions form a cohesive, HIPAA–compliant automation ecosystem that keeps RCM operations fast, accurate, and scalable.

Which brings us to the following point: 

At Floautomationics we focus exclusively on automating what matters most in U.S. healthcare revenue cycle management – no generic automations here.

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