Surgery Partners spine and revenue-cycle working session¶
Status: Draft | Last reviewed: 2026-10-06
Use this proposed demonstration to address the working-session questions about a spine procedure in 14 days, an $8,500 estimated patient responsibility, and eligibility operations across 150 patients and 10 facilities. The AI completes routine access and financial-navigation work. A human uses a live Copilot for unresolved out-of-network agreement terms and consequential financial decisions.
This is a scenario and evidence plan. No clinical or payer requests, patient calls, contracts, bookings, charges, collection activity, or deployments were performed. Operational rates and comparable-client outcomes have not been established.
Use the five-minute recording script for the current video. It applies the later review feedback: the AI completes initial verification, a live representative uses Copilot to respond to affordability concerns, and Daniel books a counselor callback. This working-session document retains the extended financial and operational scenarios.
Proposed demonstration¶
Show three connected views:
- Operations: 150 synthetic new scheduling records arrive across 10 facilities. Eligibility and authorization workflows classify work, preserve source evidence, and identify exceptions.
- Patient call: The Voice Agent handles a selected patient's verification, insurance facts, required information, explanation of options, standard affordability questions, and permitted registration.
- Live human continuation: A senior patient-access/financial specialist takes over the same call to discuss an unresolved single-case agreement and an exception to the standard financial arrangement. The Copilot responds to the conversation and assists with reviewed actions.
The main patient is Daniel Reed, an adult scheduled for multi-level lumbar spine surgery in 14 days. The treating team has selected a hospital setting. The hospital is out of network; the surgeon and other expected billers require their own verified status. A potential single-case agreement, or SCA, and prior authorization are both tracked.
All people, providers, dates, amounts, benefit terms, contracting proposals, and payment programs in this scenario are fictional. Do not assume this spine procedure is suitable for an ASC. The 10-facility operations view and any ASC comparison cohort are separate from the clinical setting chosen for this individual.
Keep the clinical, contractual, and financial facts distinct¶
| Record | Demo meaning |
|---|---|
| Scheduled date | Reserved procedure date 14 days away; not evidence of completed financial or clinical clearance |
| Clinical plan | Surgeon-authored procedure, spinal levels, clinical rationale, and intended setting |
| Coding | Reviewed planned procedure/diagnosis codes, units, modifiers, and levels, where applicable |
| Eligibility | Exact patient/plan, coverage dates, and current benefits; revalidation needed before service |
| Provider network | Separate evidence for hospital, surgeon, anesthesia, and other ordered services/billers |
| Prior authorization | Requirement, submitted evidence, payer decision, approved scope and validity, with distinct pending states |
| SCA | Requested, negotiating, received for review, or executed; scoped by patient, parties, services, dates, and terms |
| Patient estimate | Versioned calculation with assumptions, included billers, exclusions, and conditional status |
| Financial counseling | Patient understanding, budget preference, assistance review, selected terms, and unresolved questions |
| Clinical readiness | Treating-team review of preparation, test results, urgency, and timing |
| Claim/payment | Post-service claim, adjudication, actual patient responsibility, and posted cash |
An authorization acknowledgment is not an approval. An approval does not execute an SCA. An agreed provider rate does not by itself establish the patient's cost sharing or every biller's treatment. Read those terms from the actual plan and executed agreement rather than inferring them.
The $8,500 estimate¶
Use a conditional estimate to explain how the proposed financial arrangement would work. The fixture assumes a $5,000 remaining deductible and 20% coinsurance on the next $17,500 of allowed charges, giving $8,500 for the specified services. The remaining out-of-pocket limit in this fictional calculation is $9,000.
Assumed allowed total $22,500
Remaining deductible $5,000
20% of the remaining $17,500 $3,500
Estimated patient responsibility $8,500
These figures assume the requested patient-benefit treatment and service scope are accepted. They are not actual spine prices or confirmed terms of an unsigned SCA. The current out-of-network exposure remains unresolved until the necessary evidence establishes it.
The patient component should say Estimated $8,500 if the listed agreement and benefit assumptions are confirmed. It should identify what is included and what still needs review. It must not display this figure as a guaranteed maximum, settled debt, or amount due today.
Include ordered services such as anesthesia, implants, assistant-surgeon or monitoring services in the scope review when applicable. Do not assume those services are required for every spine case, or that an agreement with the hospital automatically covers independent billers.
Fourteen-day operating plan¶
These are proposed internal milestones, not payer response guarantees or universal clinical deadlines. The team uses the real payer/product requirements, patient circumstances, and surgeon's urgency assessment. Document clinical urgency; do not label a case urgent solely because its scheduled date is close.
| Timing | AI/workflow contribution | Accountable people | Expected evidence or decision |
|---|---|---|---|
| Day 0 / T−14 | Validate intake; check eligibility, benefit dates, network and authorization requirements; flag the OON case immediately | Scheduling owner, clinical coordinator, eligibility/authorization specialist | Complete identifiers, clinical setting, source responses, named case owner |
| T−14 to T−12 | Assemble the payer-specific packet; identify missing records; submit permitted requests and track receipts; prepare SCA review | Authorization specialist, surgeon/coding team, contracting lead, payer | Submitted request, genuine clinical evidence, SCA owner and channel |
| T−12 to T−7 | Track responses; request missing facts; prepare estimates and alternatives; conduct the AI-to-human patient call | Senior access/financial specialist, contracting lead, payer, treating team | Patient understands conditional costs; open contract/authorization questions have owners |
| T−7 checkpoint | Surface unresolved issues and feasible alternatives; prepare the case review | Surgeon/clinical lead, access owner, contracting/authorization leads | Documented plan for timing and location; no unsupported assumption of approval |
| T−3 to T−1 | Recheck eligibility, provider/service/date scope, executed terms, estimate, forms, and patient understanding | Access owner, contracting lead, clinical/pre-op team | Required decisions and readiness verified; unresolved issues escalated under facility policy |
| Procedure day | Make current statuses available to the responsible teams | Treating team and facility | Clinical decision and documented actual services |
| After service | Reconcile claim/EOB, payment postings and estimates; generate accurate statements and follow-up | Billing/coding, payer, patient financial services | Actual adjudicated responsibility, applied deposits, owned disputes and payment-plan status |
The contracting and clinical owners are notified when the risk is detected, while the AI continues useful patient work. Do not delay their work until the patient call ends.
A checkpoint does not automatically cancel or postpone surgery. Timing and clinical alternatives belong to the treating team with patient involvement; agreement execution and financial exceptions require the relevant authority. Use facility-specific rules for maintaining a provisional booking.
AI portion of the patient call¶
Plan a substantial AI segment of approximately six to eight minutes. The exact payer and agreement statuses at call start come from Salesforce-linked evidence. A fixture can show a prior authorization already approved while the SCA remains unsigned, but that approval must be a recorded prior event, not a decision invented during the call.
Verify identity and explain the purpose¶
AI: “I'm calling to help you prepare for your scheduled spine surgery and work through the insurance and cost details. Let's verify your identity, then I can show you the information while we talk.”
Use the established secure authentication and multimodal flow. Confirm privacy, current insurance details, any other coverage, contact preferences, and the existing procedure information.
Complete the routine insurance work¶
The AI reads current eligibility and explains verified deductible, coinsurance, provider network, and authorization information. It collects missing subscriber/card details, checks documents, requests missing records through approved channels, and records patient preferences. Routine evidence reconciliation and benefit explanations remain with the AI.
AI: “The hospital is outside your plan's network. The team is reviewing an agreement for this case. Your screen shows the insurance approval status separately from that agreement.”
The AI identifies the next required documents from the actual payer request. It uses surgeon-authored notes, imaging reports and prior-treatment evidence where required; it does not invent medical necessity, spinal levels, codes, or treatment history.
Explain options and the conditional estimate¶
AI: “Under the terms currently being reviewed, the estimate for the listed services is $8,500. That includes $5,000 of remaining deductible and $3,500 in coinsurance. Those figures depend on the agreement and benefit assumptions shown here being confirmed.”
Daniel: “Why would I owe that if the operation is approved?”
AI: “The procedure approval and your share of the cost are separate. Your share depends on your benefits and the final agreement. I can walk through the calculation and the open items.”
The AI compares in-network alternatives when the treating team has established their suitability and the required surgeon/resources are available. If a candidate still needs clinical review, label it accordingly. Do not substitute a surgeon or setting solely to lower cost.
Explore standard affordability options¶
Daniel: “I can't pay $8,500 all at once.”
AI: “I can check the available assistance programs and payment arrangements. Would you like to start with assistance eligibility or monthly payments?”
Retrieve actual configured policy. Collect only information needed for the chosen path and clearly state included billers, interest/fees, term, due dates, and any eligibility decision still pending.
An illustrative offer could be $500 initially plus 20 payments of $400, totaling $8,500 before any interest or fees. This is a fictional offer for the demo, not a Surgery Partners policy. It is shown only if its actual configured terms and covered billers support it. Record affordability preferences without charging, enrolling in credit, or committing to a still-conditional balance.
An $8,500 balance is not itself a human-transfer trigger. For a fully verified in-network case with acceptable standard terms, the AI can complete the ordinary booking and financial-navigation workflow.
Complete permitted registration and prepare the decision¶
The AI fills verified registration information, collects eligible administrative acknowledgments, checks the existing pre-op plan, and records transport/home-help needs. It completes signatures and bookings only where their prerequisites and grants allow.
The patient screen now contains the proposed care option, cost assumptions, assistance/payment preferences, completed administrative work, and the precise unresolved issues.
Transfer at the consequential exception¶
Daniel: “I want to keep this surgeon and date. But I can't agree to $8,500 and then get a much larger out-of-network bill. Can someone confirm what this agreement actually covers and help me move forward?”
AI: “I've verified the available benefits, prepared the estimate, and recorded your payment preferences. The unresolved point is the agreement's treatment of your costs and the services it covers. I'll connect you with the specialist who owns your case to review those terms and the next steps with you.”
Confirm consent to transfer as appropriate. The human receives the evidence and completed work. The AI neither promises protection that has not been established nor obtains a broad financial waiver to bypass the issue.
Live human and Copilot portion¶
The senior patient-access/financial specialist takes over the same call and patient screen. Their role coordinates the case; it does not give them unlimited authority to bind the payer, execute provider contracts, waive balances, or decide clinical timing.
Human: “Daniel, I have the surgery details, the estimate assumptions, and the payment preferences you've already discussed. Let's review the agreement questions and make sure you know what is confirmed and what still needs a decision.”
| Patient question | Copilot surfaces live | Human response or reviewed action |
|---|---|---|
| “Insurance said yes. What's missing?” | Authorization decision next to SCA execution status | Explain the actual completed and pending steps |
| “Is $8,500 the most I could pay?” | Benefit assumptions, cost-sharing clause, biller scope and unresolved terms | Explain the conditional estimate; send specific gaps to the authorized contracting owner |
| “Does this cover the surgeon and anesthesia too?” | Provider-by-provider network/agreement matrix | Identify verified coverage and separate unresolved billers |
| “What if they won't finish it before my date?” | Countdown, payer follow-ups, clinically reviewed alternatives, and responsible owners | Agree on the next update and coordinate a timely clinical/access review |
| “I need lower payments or more time.” | Facility assistance policy, eligible offers and exception authority | Review supported terms or submit an owned exception request |
| “Can I keep my date while this is resolved?” | Reservation policy and current clinical/financial status | Preserve a permitted provisional plan; do not promise a clearance that is still missing |
The Copilot should highlight the exact clause or missing field behind a concern, with document version and provenance. Draft terms remain labeled draft. A friendly explanation is not a signed agreement.
For the main exception fixture, the specialist can approve or route a supported deferral of the initial payment, confirm the named contracting/authorization owners, set a dated follow-up before the next checkpoint, and publish a written conditional patient plan. Each action has a Salesforce receipt.
If the required executed agreement and authorization are already present in another fixture, the human can verify them and complete the remaining reviewed actions during the call. If they are pending, that fact survives the wrap-up. Do not stage an unexplained instant insurer approval to manufacture resolution.
Once external decisions arrive, automation revalidates the exact procedure, site, dates, network/contract scope and estimate. The AI can then deliver the confirmation, remaining forms, payment terms, and clinician-approved preparation instructions. The original two-day reminder and medication-to-nurse handoff can follow later.
Eligibility at 150 patients across 10 facilities¶
Seed 150 clearly labeled synthetic scheduling events, 15 for each demo facility. Use the same record and workflow contract for each patient; reserve the detailed patient call for the highlighted spine case.
The operations view should show:
- New records, checks in progress, verified results, and unresolved work by facility.
- Exact source timestamps and transaction references on each eligibility check.
- Separate eligibility, authorization, network, agreement, financial, and clinical statuses.
- Missing member details, inactive/conflicting coverage, possible other coverage, expiring authorization, and unverified providers.
- Days until procedure, accountable owner, next action, and due time.
- The original request and latest response when a reviewer opens a case.
Use bounded concurrency, per-payer limits, deduplication, and retries that do not create duplicate requests. Re-run checks when insurance, provider, procedure, or service date changes, and near service according to policy.
An eligibility response does not replace network verification, authorization review, or an executed agreement. Automatic clearance follows configured verified prerequisites; partial data routes to the appropriate work queue.
Display separate labels for external live transactions, sandbox transactions, and replayed synthetic payer responses. Reading a saved synthetic response from live Salesforce demonstrates integration with Salesforce; it does not demonstrate a live connection to that payer.
Tools to demonstrate and capabilities to verify¶
| Function | Proposed integration | Proof to show |
|---|---|---|
| Eligibility/benefits | Configured clearinghouse or payer API/EDI channel; supported portal workflow where needed | Request/response IDs, scope, timestamp and normalized fields |
| Authorization | Payer-specific electronic or approved submission channel | Requirements, submitted evidence, actual receipt and subsequent decision |
| SCA | Controlled agreement repository and approved contracting process | Version, parties, service scope, cost-sharing terms, approvals and signatures |
| Estimation | Verified contracted/negotiated rates plus benefit and clinical billing inputs | Versioned inputs, calculation, exclusions and reviewer history |
| Financial assistance/plans | Facility-approved policy and patient financial-services integration | Eligibility decision, scope, terms, acceptance and approval |
| Payments | Authorized payment processor and posting integration | Actual settled receipts, refunds and ledger reconciliation |
| Salesforce/Copilot | Patient, procedure, payer evidence, documents, Tasks/Cases, call and reviewed actions | Record IDs, source links, live updates and persisted outcomes |
The repo review establishes reusable Salesforce, Voice Agent, authentication, multimodal and Copilot patterns. It does not establish a selected commercial eligibility gateway, certified patient-estimation engine, active SCA integration, or this proposed payment program. Demonstrate the actual configured tool when selected; label unimplemented connectors as such.
CMS HETS is a Medicare eligibility example, not a universal commercial-payer endpoint. Payer API availability and supported transactions must be checked per product/channel.
Post-service patient collections¶
For the insured high-deductible patient, reconcile claims and EOBs before treating the estimated $8,500 as final patient responsibility. Apply posted payments/deposits, contractual adjustments and approved assistance; explain material changes and obtain the required revised agreement.
Send accurate itemized statements and secure payment options through permitted channels. Track plan installments, actual cash, failures, disputes, assistance requests, credits and refunds. Route clinical/payer disputes to their owner and follow applicable policy for pausing contested collection activity.
The AI can explain routine statements, provide receipts, remind patients about agreed payments and offer permitted standard arrangements. A promise to pay or a signed plan is not cash collected. Material disputes, unsupported fees, hardship exceptions and collection actions beyond its grant receive the required human review.
Separate uninsured self-pay from insured patient responsibility when reporting outcomes. Different payer, procedure, facility, balance-size and aging mixes should not be presented as comparable without explanation.
Working-session measures and claims¶
The questions ask for achieved rates. None have been verified in this workspace for comparable ASC clients. The presentation must distinguish an implemented capability, a synthetic demonstration, a target, and a measured operational result.
| Measure | Proposed definition and reporting |
|---|---|
| Eligibility straight-through completion | Cases with all required verification fields resolved without manual intervention / eligible scheduled cases; show incomplete/pending separately |
| First-pass authorization approval | Original requests approved without additional-information cycles, resubmission or appeal / requests with a terminal payer decision in the defined cohort; report pending and excluded cases |
| First-call authorization | Clarify whether the client means a decision during the first payer call, first-contact resolution, or first-submission approval; report the agreed measure without counting submission receipts as approvals |
| Authorization turnaround | Time from complete submission to payer decision; show median/tail, payer and urgency cohort |
| Authorization-related denials | Unique adjudicated claims with the defined authorization-related denial / applicable adjudicated claims; distinguish initial denial from final outcome |
| Total patient collection yield | Net patient cash applied, including applicable deposits, / adjusted adjudicated patient responsibility in a fixed service cohort; bad-debt write-offs do not silently shrink the denominator |
| Post-service collection yield | Net post-service cash applied / adjusted unpaid patient responsibility at the cohort's first patient statement, with later adjustments disclosed |
| Comparable ASC outcomes | Report facility/procedure/payer/balance mix, observation window, aging at 30/60/90/180 days, exclusions and sample size |
Record plan enrollment separately from collections. Do not infer an operational rate from the 150-case fixture or borrow a vendor's performance claim as a TrueServe/Surgery Partners result.
To reduce avoidable authorization rework, validate patient, plan, provider/site, reviewed procedure/levels/codes, service dates, required evidence, and authorization validity before submission and again after changes. Track denial reasons and repeat failures so the team can test whether these controls improve the measured outcome.
Research sources and limits¶
Sources were retrieved October 6, 2026. CMS's eligibility page describes Medicare HETS 270/271. Its prior-authorization fact sheet identifies specified impacted payers and phased requirements; it does not establish universal current API availability. The financial-assistance guide supports facility-specific assistance inquiry and payment options.
https://www.cms.gov/medicare/coding-billing/electronic-billing/eligibility-inquiry
https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f
https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/guides-resources/apply-financial-assistance
https://www.healthcare.gov/glossary/preauthorization/
Carrum Health's public SCA overview describes patient-specific provider/payer arrangements and negotiated payment terms. It is a vendor's perspective, not a payer rule or independent evidence of clinical quality or financial outcomes; its comparative marketing claims are not used here.
https://carrumhealth.com/blog/what-is-a-single-case-agreement/
No applicable payer's actual SCA template or clinical spine-authorization policy was supplied or verified. The agreement review fields and operating checkpoints above are proposed controls. A build needs the actual payer/product policy, contracts, facility authority, clinical pathway, estimator inputs, and operating evidence.