Surgery Partners access and affordability variation¶
Status: Draft | Last reviewed: 2026-10-06
Use this alternative to the original orthopedic script when the demonstration should emphasize coverage, affordability, appropriate in-network scheduling, and the work needed to support reimbursement. The patient gets clear choices and a manageable next step. The revenue-cycle team handles the supporting evidence and payer process through Salesforce.
This is a proposal only. No agents, Salesforce records, payer requests, bookings, payment arrangements, or deployments were created.
For the current combined Voice Agent and live Agent Assist video, use the five-minute recording script. The autonomous voice and exception handoff remains an extended alternative: the AI prepares a hospital-change proposal, then a human uses Copilot to review existing payments, financial exceptions, and the final booking change.
Story and demonstration structure¶
Patient experience name: Surgery Partners | Plan My Surgery.
Elena Brooks needs a right knee replacement and wants to keep Dr. Maya Chen. Her employer changed insurance plans, she worries about a large upfront bill, and she is considering postponing. The agent verifies her current plan, compares two clinically appropriate hospitals where Dr. Chen operates, and helps her find an affordable arrangement.
The preferred hospital needs a complete authorization packet. A revenue-cycle specialist uses the Copilot to obtain missing therapy documentation, check the selected hospital and procedure against the request, and submit the reviewed evidence. After the payer decision and resource confirmation arrive, the Voice Agent confirms the booking and explains preparation.
All patient, clinician, hospital, payer, policy, price, and payment-plan details in this variation are fictional. The two hospitals and their programs are not represented as actual Surgery Partners facilities or offers. This is an independent version of Elena's story; its financial facts do not overwrite the original fixture.
| Part | What the audience sees |
|---|---|
| Patient call | Authentication, insurance update, preferences, option comparison, affordability, and a provisional date |
| Salesforce interlude | Copilot-assisted work on the authorization packet and financial arrangements |
| Confirmation call | Current payer decision, confirmed booking, agreed financial plan, registration, and preparation |
| Optional continuation | The original two-day reminder and medication-to-nurse handoff |
The authorization interlude represents elapsed time. Do not suggest that a new payer approval normally arrives within the patient call.
Studio assets¶
| Asset | Responsibility |
|---|---|
| Surgery Access Voice Agent | Collect missing information, explain verified findings, compare feasible options, and help the patient choose |
| Revenue-cycle workflow | Check benefits and network evidence, collect authorized records, submit/track requests, and notify staff of exceptions |
| Revenue Cycle Copilot | Help a specialist review evidence, resolve discrepancies, handle affordability exceptions, and document decisions |
| Booking and Preparation Voice Agent | Reverify the patient, confirm completed work, book the chosen resources, and explain approved next steps |
The workflow can run routine checks in the background. The Copilot supports a human specialist when a payer needs additional information or a financial option needs review. These are proposed assets and integrations.
Demonstration fixture¶
Use America/New_York for both synthetic hospitals, and display times in Eastern.
| Detail | Value |
|---|---|
| Clinical context | Surgeon has ordered right total knee replacement and documented suitability for either hospital's outpatient pathway |
| Surgeon preference | Keep Dr. Chen; discuss another surgeon only with patient agreement and the required clinical coordination |
| Travel preference | Up to 45 minutes |
| Insurance issue | Same insurance brand, different employer plan/group; old card remains in the record |
| Patient concern | “I might have to put this off if I have to pay several thousand dollars at once.” |
| Patient budget | About $200 initially and no more than $175 per month |
| Candidate A | Riverside Hospital, November 12, 20-minute illustrative travel time |
| Candidate B | Lakeview Hospital, November 19, 35-minute illustrative travel time |
| Selected option | Lakeview, with Dr. Chen |
| Authorization issue | Payer requests a recent physical-therapy completion note; receipt has not yet been established |
| Patient's contribution | Identifies the therapy practice; does not have to reconstruct or argue the clinical case |
Use live route estimates if travel time becomes a product feature; the two times above are illustrative.
Patient call¶
1. Start with the concern¶
Use the original private-conversation, authentication, and secure multimodal flow before discussing patient information.
Agent: “Dr. Chen's office asked us to help arrange your knee surgery. I can help check your insurance, compare available dates and hospitals, and go through what you may need to pay. What's your biggest concern about moving forward?”
Elena: “The bill. My work changed our insurance, and I can't pay several thousand dollars at once.”
Agent: “Let's check the current plan first. Then I can show you the options and any payment or assistance programs available through the hospital.”
Component: Your coverage and priorities. Display current insurance status, preferred surgeon, travel limit, availability, and the patient's stated concern. Avoid asking the patient for information already verified in the record.
2. Collect the information that changes the outcome¶
Agent: “I see the previous insurance card on file. Would you upload the front and back of your new card through this secure screen?”
The component extracts the payer, exact plan/group, member information, and subscriber relationship. The patient checks the extracted information. Low-confidence or conflicting values require confirmation.
Agent: “Is this your only active health plan?”
Elena: “Yes.”
Agent: “And would you prefer to stay with Dr. Chen if there's a suitable option?”
Elena: “Definitely. I can travel a little farther if that helps.”
Agent: “What travel time would work for you?”
Elena: “About 45 minutes.”
Background work: Validate the current member/plan, benefit dates, remaining deductible and out-of-pocket amounts, applicable referral/authorization requirements, and other-coverage answers. Flag unresolved coordination of benefits or other-payer issues. Where relevant, staff verify accident/work-related coverage rather than guessing from the diagnosis.
Network checks use the exact plan, provider/billing identity, location, and intended service date. Verify the surgeon, hospital, and expected anesthesia group separately. Current eligibility is evidence for the estimate; recheck coverage near the service date.
3. Compare suitable surgeon, hospital, and date combinations¶
Both candidates have documented clinical suitability and Dr. Chen's privileges. The agent does not select a care setting on cost alone.
Agent: “I found two options within your travel range where you can stay with Dr. Chen. Both hospitals, Dr. Chen, and the expected anesthesia groups check as in network for your current plan.”
Component: Compare your surgery options
| Option | Riverside Hospital | Lakeview Hospital |
|---|---|---|
| Surgeon | Dr. Chen | Dr. Chen |
| Date | Thursday, November 12 | Thursday, November 19 |
| Setting | Approved outpatient hospital pathway | Approved outpatient hospital pathway |
| Illustrative travel | 20 minutes | 35 minutes |
| Estimated patient share | $3,600 | $1,800 |
| Network checks | Verified for the listed providers | Verified for the listed providers |
| Authorization | Required, pending for this option | Required, pending for this option |
| Availability | Available when last checked | Available when last checked |
Use the same scope for both estimates: hospital, surgeon, and anesthesia. Show pre-op tests, rehabilitation, medicines, and optional support as separate estimates or clearly marked exclusions.
The synthetic calculation assumes $500 remaining deductible, 20% coinsurance afterward, and $5,000 remaining out-of-pocket maximum:
- Riverside: $16,000 estimated allowed total; $500 + 20% × $15,500 = $3,600.
- Lakeview: $7,000 estimated allowed total; $500 + 20% × $6,500 = $1,800.
- Neither option reaches the remaining out-of-pocket maximum in this fixture.
These allowed amounts and benefit rules are demo inputs, not researched market prices or actual plan benefits.
Agent: “Lakeview's current estimate is $1,800 for those services. That's $1,800 less than the Riverside estimate. The difference comes from the allowed charges used in your plan's estimates.”
Elena: “I'd rather drive farther and save that money. November 19 works.”
Agent: “I'll record Lakeview as your choice. The insurer still needs to finish its authorization review before I can give you a confirmed booking.”
Action: Record the choice and create a provisional reservation only if the hospital's scheduling rules permit it. Show its expiry or review deadline. Do not silently create a confirmed appointment from the patient's selection.
4. Make the financial arrangement understandable¶
Elena: “Even $1,800 would be hard all at once.”
Agent: “I can check whether you may qualify for assistance, or show the hospital's available payment arrangements. Which would you like to explore first?”
Elena: “Monthly payments. I could manage about $200 to start and $175 a month.”
The tool retrieves a facility-approved offer with eligibility, included billing entities, amount, payment schedule, interest, fees, expiry, and terms. Patient budget disclosure is optional and does not authorize a charge.
Agent: “This demo program offers $200 initially and ten monthly payments of $160, with no interest or fees. It covers the hospital, surgeon, and anesthesia amounts listed here. Does that fit the budget you described?”
Elena: “Yes.”
Component: Your payment options. Show total estimated responsibility, initial amount, monthly schedule, covered billers, exclusions, and full terms. Offer a financial-assistance screening or a counselor if the arrangement does not work.
Agent: “Please review the terms on your screen. Nothing will be charged from this conversation. The final balance will reflect the actual services and your insurer's processed claims.”
Action: Save the selected offer and exact terms. The main fixture allows offer acceptance now and activation after the hospital's booking conditions are met. Any material estimate change needs a revised offer and patient agreement.
This all-provider, zero-interest program is a specific fictional assumption. If a real hospital plan covers only its own bill, the component and spoken explanation must show the surgeon/anesthesia bills separately. Do not describe a hospital-only plan as financing the entire episode.
Screen for assistance under the actual facility's policy when requested; do not promise eligibility, discount approval, or universal availability. Payment plans are optional. A declined plan or inability to pay creates an owned counseling task and a clinically appropriate access path under facility policy, not an automatic agent decision to cancel care.
5. Explain the remaining work without making the patient manage it¶
Agent: “The insurer has asked for the completion note from your physical therapy. Which practice treated you?”
Elena: “Harbor Physical Therapy. I already finished that.”
Agent: “Thank you. The authorization team will request the note through the center's records process. You don't need to repeat your treatment history to the insurer. Your screen shows who's handling it and when to expect the next update.”
Component: What happens next
| Step | Patient-facing status |
|---|---|
| Current plan | Checked |
| Preferred hospital and surgeon | Selected; network checks recorded |
| Expected cost | Reviewed; payment offer selected |
| Insurance review | Team obtaining the requested therapy note |
| Surgery date | Provisional; confirmation pending |
| Next update | Named owner and October 15 contact target |
Agent: “I'll update you by Thursday, even if the insurer's review is still in progress. Once the approval and hospital booking are confirmed, we'll review registration and preparation together.”
An update commitment is owned outreach, not a promised payer decision. If the reservation expires, seek renewed availability and contact the patient about material changes.
Salesforce interlude and Revenue Cycle Copilot¶
The audience now sees the staff workspace. The patient has finished the call.
Case: Elena Brooks — right knee replacement — preferred date November 19 — Lakeview Hospital.
Copilot briefing: “Elena prefers Dr. Chen at Lakeview and selected the $1,800 estimate with the $200-plus-ten-payments offer. The insurer requested the therapy completion note. The earlier draft references Riverside; review the selected hospital before submitting the revised packet.”
| Copilot card | What the specialist sees or does |
|---|---|
| Coverage and network evidence | Exact plan, verification source/date, and separate surgeon/hospital/anesthesia checks |
| Authorization requirements | Payer-returned documentation request, case reference, selected site, procedure/side, and requested service window |
| Missing documentation | Therapy-practice contact, request receipt, pending document, assigned owner, and next follow-up |
| Evidence review | Retrieved therapy note and surgeon note with dates and source links; discrepancies remain visible |
| Site/procedure match | Confirm Dr. Chen, Lakeview's billing/site identity, right knee, and November service date |
| Patient affordability | Versioned estimate, patient-selected budget, offer coverage, terms, and assistance/counseling status |
| Suggested action | Review the packet and submit it to the configured payer channel |
The specialist confirms the genuine records and selected-site information. The workflow records submission and subsequent payer responses. It must not infer completed therapy from the patient's recollection, invent a medical-necessity narrative, or reuse an approval for a different site without verification.
For this rehearsal, show an explicit jump from October 13 to October 15. The payer response now records approval for the chosen procedure, surgeon/site, and valid service dates. A submitted request, request receipt, or completed internal review cannot produce this status.
The Copilot can also support a live financial counselor if the patient requests one. That optional handoff carries the same estimates, preferences, and unanswered question so the patient does not repeat them.
Confirmation and preparation call¶
Reverify identity and reread the current episode before disclosing the result. Confirm slot availability, authorization scope, estimate freshness, and payment-offer validity. Resolve changes before promising the original choice.
Agent: “Your insurer has approved the requested right knee replacement at Lakeview with Dr. Chen for the recorded date range. The hospital has confirmed November 19. Your current estimated share is still $1,800.”
Elena: “And the monthly payments still work?”
Agent: “Yes. Your selected arrangement is still $200 initially and ten monthly payments of $160 under the terms you've reviewed. The secure screen shows when it starts and which bills it includes.”
Only say the arrangement is active after its conditions and required acceptance are satisfied. If payment collection is later enabled, use the approved secure payment component and store transaction receipts; never ask the patient to speak card details.
Elena: “So insurance approval means they will pay everything else?”
Agent: “It means the authorization requirement for the approved request has been met. The estimate still depends on your coverage when you receive care, the services provided, and how the claims are processed. You can see the included services and remaining assumptions here.”
Component: Your confirmed surgery plan
- Procedure, side, surgeon, hospital, date, and separately labeled arrival/start times.
- Authorization decision and scope in plain language.
- Current estimate and chosen financial arrangement.
- Registration and required signature checklist.
- Pre-op appointment and ordered tests.
- Transport, responsible-adult, and home-support needs.
- Approved preparation instructions and outstanding clinical review.
Agent: “Now that your surgery is booked, let's go through preparation. Your pre-op appointment is October 29, three weeks beforehand. Bring your current medicines and supplements list. Your checklist also covers the center's washing instructions, getting your home ready, and arranging someone to take you home.”
Follow the original registration, consent, pre-op booking, and support components. Confirm appointments and services through actual receipts. Read final medication and fasting instructions only when the responsible clinical team has approved them; do not generate them from the financial-clearance result.
Agent: “Before we finish, what is your surgery date, and what payment arrangement have you selected?”
Elena: “November 19 at Lakeview. Two hundred initially, then ten payments of $160.”
Agent: “That's right. Your plan is saved here, along with the team to contact if your insurance or circumstances change.”
Salesforce records and reimbursement handoff¶
Extend the original data contract with the following record-backed information. All proposed new records require target-org schema verification.
| Record or extension | Required evidence |
|---|---|
| Coverage snapshot | Exact member/plan, effective dates, subscriber/other coverage, source, timestamp, recheck status |
| Provider-network verification | Surgeon, hospital, anesthesia billing/location identifiers; exact plan; source and service-date applicability |
| Candidate care option | Clinical suitability, surgeon privileges, feasible resources, travel preference, slot and estimate versions |
| Authorization case | Request and response IDs, required evidence, source documents, site/procedure/date scope, status, owner, expiry |
| Patient estimate | Included billers/services, allowed amounts, benefit assumptions, exclusions, version, patient acknowledgment |
| Assistance/payment option | Facility policy or offer, included billers, eligibility/decision, schedule, interest/fees, consent and activation status |
| Provisional/confirmed booking | Authoritative resource receipt, conditions, expiry, confirmation, and change history |
| Pre-service work checklist | Coverage, documentation, authorization, coding review, financial discussion, registration, and open exceptions |
| Post-service billing handoff | Actual services, authenticated clinical documentation, coding review, claim/acknowledgment references, adjudication and reconciliation |
Keep coverage verified, authorization approved, financial arrangement accepted, booking confirmed, clinical preparation reviewed, and claim paid as separate states. Pre-service checks support reimbursement; they do not establish payment.
After the procedure, the billing team uses actual documented services and coding review to prepare the claim. Differences from the authorized scope require review. Track claim submission, acceptance, denial/adjustment, remittance, and the reconciled patient balance separately.
The main demo ends after booking and preparation. A later optional billing scene can show the claim and patient-plan reconciliation when actual remittance evidence exists.
What to measure and rehearse¶
Measure whether the patient finds an acceptable option, understands the estimate and terms, and reaches a confirmed booking. Operational measures can include time awaiting documents, authorization turnaround, rework, estimate changes, and cancellation reasons. Measure reimbursement and denial outcomes only after claims adjudicate; do not promise a reduction before testing.
Rehearse an insurance-card correction; non-matching surgeon/facility network status; a clinically unsuitable low-cost option; another insurer or work-related coverage; missing documentation; expired provisional slot; incorrect authorization site; unaffordable payment offer; hospital-only payment coverage; and a benefit-year change before surgery.
In each case, show the actual unresolved condition, accountable owner, and next step. The patient should see what matters to their choice without being asked to operate the payer workflow.
Research supporting the variation¶
Public sources were retrieved on October 6, 2026. These establish general distinctions, not Surgery Partners' local policies or this fictional patient's benefits.
Network and authorization: HealthCare.gov defines networks through contracted providers/facilities and explains that preauthorization is not a coverage/payment promise. These support plan-specific matching and separate approval/payment states.
https://www.healthcare.gov/glossary/network/
https://www.healthcare.gov/glossary/preauthorization/
Financial assistance and payment options: CMS advises checking a facility's assistance policy and describes possible payment arrangements. IRS guidance explains financial-assistance requirements for tax-exempt hospitals, including provider scope. Those tax-exempt requirements must not be generalized to every Surgery Partners location or independent biller.
https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/guides-resources/apply-financial-assistance
https://www.irs.gov/charities-non-profits/financial-assistance-policies-faps
Payer integration: CMS's interoperability/prior-authorization fact sheet distinguishes operational changes and phased API requirements for specified impacted payers. Do not assume every employer plan has a working real-time authorization API in October 2026. Discover actual channels and capabilities; preserve asynchronous submission, more-information, approval, and denial states.
https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f
Existing research notes cover Surgery Partners, orthopedic preparation, anesthesia, consent, estimates, and Salesforce data models. No new clinical regimen is proposed in this variation.