Implemented a Complete Overhaul of Revenue Cycle Management Program for Large Hospital-Owned Cardiology Clinic

A Large Cardiology Clinic In Central Texas

Enhanced Revenue Solutions (ERS) by Infinx aligned with a large cardiology clinic (Clinic) in Central Texas after they were unable to meet their corporate cash flow goals for the preceding year. With 50-60 providers specializing in cardiology and electrophysiology, the Clinic had a considerable amount of work to be done in all phases of revenue cycle management (RCM). ERS was engaged by the parent hospital management system to improve overall cash flow and bring AR in line with corporate expectations.

With over $1M in improved quarterly collections, the Clinic and their hospital partners were thrilled and engaged ERS on a continuing basis in all facets of the Clinic’s RCM.

Understanding the Current Revenue Cycle Workflow

ERS performed an in-depth analysis of the entire revenue cycle beginning with patient access and insurance verification, prior authorization, through the coding process, claims generation and submission, through the insurance payment and denial process:

  • Lag time in the charging and claim submitting process
  • Issues with the coding component
  • Missing or incomplete prior authorizations
  • AR recovery through denied claims.

The First Challenge – Charge Lag

In doing an in-depth analysis of the RCM process at the Clinic, ERS first identified a significant lag in completing the charging process and submitting claims. It was quickly determined that the Clinic suffered from two roadblocks:

  • Providers submitting charges timely
  • Billing office work structure for completing the claims submission process

With an overall goal of claims submission within 24-72 hours of service, ERS was able to shave a full two weeks off the time-frame that was currently being used by the Clinic. First, by restructuring and streamlining the billing office workflow, and second, by educating and mobilizing the providers as active participants in their own RCM.

The billing office improvements, once implemented, were easily maintained by Clinic leadership. However, as with many Clinics, keeping the providers motivated to submit their claims information and supporting documentation in a timely manner will be an ongoing activity.

The Second Challenge – Coding

Using in-house coders, the Clinic was suffering from rejected and denied claims due to inaccurate coding and not coding to the highest level. Additionally, reimbursement suffered because of bad or missing documentation.

Understanding the complexities of a hospital-based specialty practice with a significant percentage of Medicare patients, it was decided that the optimum solution was to have ERS step in and perform the coding of all claims to ensure accuracy, timeliness, and maximized reimbursement.

As the Clinic RCM was stabilized during 2017 and 2018, ERS trained the billing employees to reassume the coding function and oversaw the process until they were proficient.

The Third Challenge – Insurance Verification and Prior Authorization

ERS’s work progressed and it was identified that 80% of the Clinic’s claim denials and rejections were due to bad or non-existent insurance verifications and incomplete or missing prior authorizations.

These two issues were reviewed in detail and clear solutions were implemented as follows:

  • ERS tackled the insurance verification problem by implementing strong guidelines at the front desk and scheduling areas with training to support each function.
  • The prior authorization process was then outsourced to ERS which implemented strong protocols that could be handed back to the Clinic when it was deemed appropriate.

By implementing solutions for these three challenges, ERS improved the quarterly collections for the Clinic in the first two quarters by over $1M with no real increase in production.

ERS was able to raise the Medicare Modeled Collections Rate by 10% in the first quarter.

The Fourth Challenge – A/R Recovery through Denied Claims

As a separate project, the Clinic engaged ERS in an all-out A/R Recovery effort. ERS’s recovery team worked diligently and through research and re-submittal,

ERS was able to collect on 63% of denied claims that were 120 days or older.

The On-Going Partnership

The initial phases of the project proved to be highly successful and ERS was engaged to partner with the Clinic to manage their ongoing RCM process from prior authorization through the final claims denial procedure. Incrementally, the Clinic continued to experience improvements in their bottom line and improve their AR days outstanding percentages.

ERS was able to help the Clinic and the providers recognize significant improvements in their overall financial health and regain a position of esteem within the larger hospital management system.

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