The client is the largest radiology provider in the nation, having grown significantly over the past 13 years. Since 2006, the company has quadrupled in size to 344 locations employing 8000 people and 500 radiologists. Their imaging centers specialize in PET/CT, MRI, CT, nuclear medicine, mammography, ultrasound, and X-rays. They have regional networks in New Jersey, New York, Delaware, Maryland, California, and Florida.
Executive Summary and Scope
A national leader in outpatient imaging services, was witnessing a gradual pileup in their 90+ aging AR inventory. It burgeoned to more than $150 million and accounted for 30% of total billed AR. With such an enormous old inventory susceptible to write-offs, the client was looking for an innovative technology-driven solution that could help them prioritize and automate resolution efforts, ensuring maximum collections from 90+ day denials and reduction of older inventories quickly. Within 9 months of implementation, Infinx was able to:
- Bring down 90+ aging AR inventory to below 12% of total billed AR
- Improve monthly collections by 15.2%
- Boost first pass payments by 36%
The Radiology Group Was Experiencing a Gradual Increase in Their 90+ A/R Inventory
The group was manually undertaking the AR resolution activities with limited workflows. But, as the inventory rose, with a limited workforce and lack of technological assistance, they were unable to keep up with the incoming and existing inventory. As a result, AR aged and subsequently turned uncollectible.
It is clear that aging AR directly contributes to a loss in revenue. The more aged the AR, the lower the chances of recovery. Every month the client was witnessing more than $25 million getting added to the inventory. They fell into a vicious loop in which more attention to 90+ AR inventory led to a lesser focus on new and current AR that eventually aged and turned into 90+ aging AR, swelling the bucket further.
The situation turned so bad that 90+ aging AR inventory crossed $ 150 million and represented more than 30% of currenthttps://www.infinx.com/wp-admin/post.php?post=13913&action=edit# billed AR. A majority of such denied claims eventually slipped their timely appeal limits and had to be written off, leaving a direct dent into their revenue as well as bottom-line financials.
The client was looking for an innovative technology-driven solution provider to prioritize and accelerate resolution efforts to ensure maximum collections from 90+ denials and reduce older inventories quickly.
Technology With Next Generation Capabilities
After evaluating Infinx’s methodology, the client was confident of Infinx’s data-driven approach to tackle the denial menace. Having an outstanding track-record of boosting performance both in terms of collections and quality for its clients, Infinx was invited to provide a solution to tackle their 90+ aging AR inventory for the client. Infinx has serviced large/medium sized imaging groups across the nation in aged AR recovery through proprietary smart technological solutions assisted by experienced denials and billing specialists.
Infinx’s proprietary solution eased the manual burden of evaluating the risk of revenue leakage for each claim due to timely filing and appeal limits of respective payers and corresponding state timely guidelines. On a tactical front, claims were screened to exclude charges with non-payable denial codes, non-payable CPT codes as per payer-provider contracts and expired appeal limits. The workable claims were segregated into various denials groups and payer groups and were fed into the Infinx Prior Authorization Software to come up with a priority work order of claims, taking their appeal limits and outstanding dollar amounts into account.
After performing a detailed root-cause analysis of various denial categories, Infinx presented a technology-based multidimensional approach to fast-track denial resolution activities.
Infinx’s Technology-Driven Solution Prioritized and Automated Resolution of 90+ aging A/R Denials Within 9 Months
Infinx started with analyzing the timely appeal limits of outstanding denial inventory to identify the set of charges that required immediate resolution efforts. Upon further examination, it was found that insurance eligibility, medical necessity, and prior authorization related rejections constituted more than 75% of all denials.
Customize AR Recovery Resolution
Customized resolution activities were designed as per industry best practices by Infinx’s AR professionals for each of the denial and DNFB (discharged, not final billed) scenarios. Some of the major activities included:
- Validating subscriber’s eligibility and rectifying patient demographic and policy details through Infinx’s Verification & Benefits module
- Discovering and updating new payer information for resubmitting claims
- Analyzing authorization requirement based on payer guidelines as per CPT and reaffirm authorization validity with date of service
- Rectifying billing errors and re-billing as per contractual instructions
- Addressing medical necessity queries and LCD denials with relevant medical records as per payer’s satisfaction
- Scrutinize duplicate reasoned denials and append modifiers for resubmission as necessary
Future Denial Prevention
The approach below will enable the client to plug revenue leakage by addressing 90+ aging AR in time and enabled them to stay on top of current denials. Long term steps and process changes included:
- Rectifying payer ID and claim address mappings between RIS, billing software and clearinghouse
- Setting up split billing correctly at the facility level
- Monitoring and acting upon global trends, LCD/NCD rules and payer specific guidelines pertaining to eligibility
- Configuring claim edit set-ups including CCI edits within billing and clearinghouse software
- Setting up technical logistics for paper submission of claims along with medical records for high dollar modalities
- Payer credentialing issues
Significant Improvement to Key Financial Metrics
The radiology group experienced a drastic improvement in key financial performance metrics on their 90+ aging AR inventory in a quick span of 9 months:
- Successful liquidation of $205 million old AR
- Collected $43 million from $172 million of 90+ AR
- Brought down 90+ aging AR inventory to below 14% of total billed AR
- Improved gross collection ratios from 23.9% to 28.41%
- Improved monthly collections from denials by $1.5 million per month or 15.2%
- Identified and fixed global issues (long term initiatives for the future) worth $37.2 million which translated in reduced AR
- First pass payments improved by 36%