CASE STUDY

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.

Let’s Optimize Your RCM Workflow

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

      1. Loria K. Putting the AI in Radiology. Radiology Today, Vol. 19, No. 1, P. 10.
        https://www.radiologytoday.net/archive/rt0118p10.shtml.
        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.
        https://kaloramainformation.com/molecular-diagnostics-market-now-larger-than-the-economies-of-50-nations-per-new-report/.
        Accessed on January 20, 2020.
      3. Atella V, Mortari A, et.al. 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. https://www.cdc.gov/nchs/products/databriefs/db317.htm.
        Accessed on January 24, 2020.
      5. PAMA Regulations, Important Update. CMS.gov, Centers for Medicare and Medicaid Services.
        https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations
        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.
        https://www.mgma.com/resources/revenue-cycle/transforming-the-prior-authorization-process-to-im.
        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. https://www.fiercehealthcare.com/practices/mgma19-no-progress-to-fix-prior-authorization-as-practice-leaders-say-it-s-gotten-worse.
        Accessed June 8, 2020.
      9. 2019 CAQH Conducting Electronic Business Transactions: Why Greater Harmonization Across the Industry is Needed, p. 2. 2020.
        https://www.caqh.org/sites/default/files/explorations/index/report/2019-caqh-index.pdf?token=SP6YxT4u.
        Accessed on January 30, 2020.
      10. Joint Authorship. Consensus Statement on Improving the Prior Authorization Process. American Medical Association. 2018. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf.
        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.
        https://www.rheumatology.org/Portals/0/Files/Coaliition-Letter-HR3107-Prior-Authorization-Reform.pdf.
        Accessed on January 30, 2020.
      12. Livingston S, Luthi S. House Committee Throws Spotlight on Prior Authorization Burden, Modern Healthcare. September 11, 2019. https://www.modernhealthcare.com/politics-policy/house-committee-throws-spotlight-prior-authorization-burden.
        Accessed on February 3, 2020.
      13. Ibid. 9.
      14. Industry Checkup: Measuring Progress in Improving Prior Authorization. American Medical Association. 2019.
        https://www.ama-assn.org/system/files/2019-03/prior-authsurvey.pdf.
        Accessed on February 2, 2020.
      15. Artificial Intelligence – What it is and Why it Matters. SAS Insights. 2020.
        https://www.sas.com/en_us/insights/analytics/what-is-artificial-intelligence.html.
        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. https://www.healthcareitnews.com/news/radnet-aifueled-prior-authorization-tech-99-accurate.
        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.
        http://investor.napcosecurity.com/2015-01-13-NAPCOs-iBridge-Technology-Named-Top-Innovation-of-2014-by-Security-Sales-Integration-Magazine.
        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. https://www.infinx.com/resourcecasestudy/integrating-preauthorization-solution-with-epic-pms-lt/.
        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.
        https://www.infinx.com/resource-casestudy/implemented-a-complete-overhaul-of-revenue-cycle-management-program-for-large-hospital-owned-cardiology-clinic/.
        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. https://aibusiness.com/industrygraphic-artificial-intelligence/.
        Accessed on February 2, 2020.
      22. Maximize Hospital Revenue with a Holistic Insurance Discovery Strategy. January 7, 2019.
        https://revcycleintelligence.com/news/maximize-hospital-revenue-with-a-holisticinsurance-discovery-strategy.
        Accessed on January 20, 2020.
      23. How Using Insurance Discovery Can Significantly Improve A/R, Infinx Blob. January 23, 2020.
        https://www.infinx.com/blog/how-using-insurance-discovery-can-significantlyimprove-a-r/.
        Accessed on January 23, 2020.
      24. 2018 Survey of America’s Physicians: Practice Patterns and Perspectives. The Physicians Foundation, Empowering Physicians/Improving Healthcare. 2019.
        https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf.
        Accessed on January 30, 2020.
      25.  New Findings Confirm Predictions on Physician Shortage. Association for American Medical Colleges. April 23, 2019. https://www.aamc.org/news-insights/press-releases/new-findings-confirm-predictions-physician-shortage.
        Accessed on February 1, 2020.
      26. Reporting appropriate use criteria in claims for Medicare Patients. American Medical Association. August 17, 2020.
        https://www.ama-assn.org/practice-management/medicare/reporting-appropriate-use-criteria-claims-medicare-patients.
        Accessed on August 19, 2020.