A Leading Outpatient-Imaging Provider Improved Collections from 90+ Aged Denials Using Infinx’s Technology Driven Approach

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 current 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%

Let’s Optimize Your RCM Workflow

Schedule a call with our team to learn how our solution can help optimize your revenue cycle.

Schedule A Demo
      1. Loria K. Putting the AI in Radiology. Radiology Today, Vol. 19, No. 1, P. 10.
        Accessed on June 7, 2020.
      2. Carlson B. Molecular Diagnostics Market Now Larger than the Economies of 50 Nations, per New Report. Kalorama Information Website. October 30, 2019.
        Accessed on January 20, 2020.
      3. Atella V, Mortari A, Trends in are-related disease burden and healthcare utilization. Aging Cell, 2019 Feb; 19(1): e12681. Published online November 29, 2018. doi: 10.1111/acel.12861.
        Accessed June 1, 2020.
      4. Cohen R, Zammitti E. High-deductible Health Plan Enrollment Among Adults Aged 18-64 with Employment-based Insurance Coverage. Centres for Disease Control and Prevention NCHS Data Brief No. 317. August 2018.
        Accessed on January 24, 2020.
      5. PAMA Regulations, Important Update., Centers for Medicare and Medicaid Services.
        Accessed on January 28, 2020.
      6. 2018 AMA Prior Authorization (PA) Physician Survey. American Medical Association, Prior Authorization Research & Reports. 2019. file:///C:/Users/katem/Downloads/priorauth-2018%20(1).pdf.
        Accessed on November 23, 2019.
      7. Yu Y, MD. Transforming the prior authorization process to improve patient care and the financial bottom line. MGMA, Knowledge Expansion Insight Article, Reimbrusement.
        Accessed June 10, 2020.
      8. Finnegan J. MGMA19: No progress to fix prior authorization, as practice leaders say it’s gotten worse. Fierce Healthcare. October 16, 2019.
        Accessed June 8, 2020.
      9. 2019 CAQH Conducting Electronic Business Transactions: Why Greater Harmonization Across the Industry is Needed, p. 2. 2020.
        Accessed on January 30, 2020.
      10. Joint Authorship. Consensus Statement on Improving the Prior Authorization Process. American Medical Association. 2018.
        Accessed on January 22, 2020.
      11. Letter to the House of Representatives in support of Improving Seniors’ Timely Access to Care Act 2019 (H.R. 3107) from 370 Associations. September 9, 2019.
        Accessed on January 30, 2020.
      12. Livingston S, Luthi S. House Committee Throws Spotlight on Prior Authorization Burden, Modern Healthcare. September 11, 2019.
        Accessed on February 3, 2020.
      13. Ibid. 9.
      14. Industry Checkup: Measuring Progress in Improving Prior Authorization. American Medical Association. 2019.
        Accessed on February 2, 2020.
      15. Artificial Intelligence – What it is and Why it Matters. SAS Insights. 2020.
        Accessed on February 1, 2020.
      16. Siwicki B. At RadNet, AI-fueled Prior Authorization Tech Shows Promise, Healthcare IT News, Global Edition. May 6, 2019.
        Accessed on January 6, 2020.
      17. Napco’s iBridge Technology Named Top Innovation of 2014 by Security Sales & Integration Magazine – Recurring Revenue Model Makes iBridge a Top Choice for Security Dealers. January 13, 2015.
        Accessed on February 3, 2020.
      18. Integrating Prior Authorization Solution with Epic PMS While Protecting PHI at a Pennsylvania Hospital Group. Infinx Case Study. 2018.
        Accessed on February 2, 2020.
      19.  Implemented a Complete Overhaul of Revenue Cycle Management Program for Large Hospital-Owned Cardiology Clinic. Infinx/Enhanced Revenue Solutions Case Study. 2018.
        Accessed January 12, 2020.
      20. Ibid. 9.
      21. *******Chhaltralia V. What Does the Future Hold for Artificial Intelligence? Industry Analysis and Graphic, AI Business. March 22, 2018.
        Accessed on February 2, 2020.
      22. Maximize Hospital Revenue with a Holistic Insurance Discovery Strategy. January 7, 2019.
        Accessed on January 20, 2020.
      23. How Using Insurance Discovery Can Significantly Improve A/R, Infinx Blob. January 23, 2020.
        Accessed on January 23, 2020.
      24. 2018 Survey of America’s Physicians: Practice Patterns and Perspectives. The Physicians Foundation, Empowering Physicians/Improving Healthcare. 2019.
        Accessed on January 30, 2020.
      25.  New Findings Confirm Predictions on Physician Shortage. Association for American Medical Colleges. April 23, 2019.
        Accessed on February 1, 2020.
      26. Reporting appropriate use criteria in claims for Medicare Patients. American Medical Association. August 17, 2020.
        Accessed on August 19, 2020.

Infinx Prior Authorization and Revenue Cycle Management Solutions

Speed Up Prior Authorizations Using Automation and Artificial Intelligence

Accelerate your approvals, collect more revenue, and improve the patient experience

Schedule A Demo