Sustainable Success: Maintaining AR > 90 days at LESS THAN 5%

Introduction

Embark on a journey into sustained success within the complex realm of Revenue Cycle Management (RCM). This case study unveils the strategies behind consistently maintaining Accounts Receivable (AR) below 5% beyond the critical 90-day mark. Discover actionable insights tailored for professionals navigating the intricacies of RCM in the U.S. healthcare landscape. Join us as we explore the keys to sustaining a lean AR balance, ensuring enduring financial excellence in healthcare operations

Industry Challenges - Insights

Problem statement

1. Denials Untouched, high denials are:

• Inefficient Eligibility & Benefits Verification.
• Higher Medical Necessity denials.

2. In-Appropriate Payment Posting.

3. Claims not followed up on time.

4. Appeals have not worked and have not followed up.

5. Resolution of claims <90 days was lagging.

Root Cause

Our objective was to comprehensively analyze the challenges posed by extended AR cycles and, in turn, equip decision-makers with actionable strategies to navigate this impending threat effectively.

1. Inefficient Eligibility & Benefits Verification

• A defined process for Eligibility and benefits Verification was missing
• Due to a shortage of staff, the actions were not taken promptly
• The eligibility process was all manual which further delayed the process

2. Higher Medical Necessity Denials

• The coding process was not streamlined
• Leveraging required tools and systems to determine efficient and compliant - reimbursement coding was not in place
• Misalignment between the services provided and the payer's criteria for necessity

1. In-Appropriate Payment Posting

• The payment poster's knowledge and lack of understanding of offsets and recoupments led to an unreconciled balance

2. Claims not followed up on time

• Lack of Prioritization: A perennial challenge in the industry, prioritizing a high volume of claims requires comprehensive data analytics and data intelligence tools which was missing
• Again, shortage of staff is another critical issue
• Overload of Work - A shortage of staff will lead to an Overload of work and impact the efficiency of productivity and accuracy

1. Appeals have not worked and have not followed up

• The consequence of timely addressal of denials, and following up on claims due to reasons highlighted above leads to Appeals not working timely

2. Resolution of claims < 90 days was lagging

• Effective claim resolutions require an organization to pull off multiple levers together concurrently
• Claims less than 90 days were not worked effectively
• Reasons, every claim requires follow-up every 30 days
• Early insights on payment denials missed has a multitude effects on current, future, and past claims.
• The multitude effect become multifold making the AR more complex and hard to collect
• Inefficient Work-Flow system.

Solutions for Root Cause - Coding Services

Root Cause

• Coding Process
• Documentation Improvement

Solutions

• Revamped coding guideline documentation upon careful review of all denials
• Coding documentation feedback by deployingSenior Coding professionals
• Tracked all denials post-go-live to reduce coding denials

Solutions for Root Cause - Cash Posting Services

Root Cause

• In-appropriatePayment posting dueto offsets andRecoupments
• Unreconciled Claim balances

Solutions

• Complete EOB review of all open claims with high priority on high $ value claims
• Reasons for recoupments, offsets tracked and streamlined by deploying Senior Payment posters
• Leveraged in-house Cash Reconciliation tools to speedy completion,

Solutions for Root Cause - Technology (Prior Auth Smart)

Root Cause

• Eligibility & Benefits Process in-effective
• No effective work-flow

Solutions

• Completed all payment posting issues
• Cleaned up by moving balance appropriately - to Patient & Insurance
• Deployed our internally developed Technology solutions
• Benefits & Eligibility Process Streamlined

Solutions for Root Cause - Technology (RevShield A.I.)

Root Cause

• Claims not followed-up Timely
• Prioritization of claims
• Comprehensive Data Analytics & Intelligence tool.

Solutions

• Extensive technology implementation to roll up to RevShield A.I.
• Implemented Machine Learning Algorithms to learn denial patterns.
• Data Intelligence modules started to provide deeper insights on Aging, Denials, Trends & patterns including Resolution Rate - # of touch resolutions

Discover the Results: Dive deeper into our case study to explore the outcomes and results of our strategies that enabled our clients to maintain AR > 90 days at LESS THAN 5%. Click here to read more!