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THE CLIENT

A Nationally Recognized Healthcare Organization

This client is one of the largest non-profit healthcare organizations in the US, with 5 hospitals and over 80 outpatient facilities in the region. Due to disparate systems, inconsistent processes, and a high volume of claims spanning multiple insurance providers, the organization faced escalating operational costs, revenue leakage, and compliance risks. Trying to manage these issues in-house threatened its ability to provide exceptional patient care.

PROJECT REQUIREMENTS

Improving Reimbursement Cycle in the Client’s Healthcare System

The client expected SunTec Data to help with healthcare reimbursement cycle optimization by -

  • Establishing a best-practice framework for revenue cycle processes across all the client’s facilities
  • Streamlining various steps in the healthcare revenue cycle, such as pre-authorization and patient eligibility verification, medical coding & charge capturing, and insurance claims processing
  • Creating a robust denial management protocol to enable quick resolution of denied claims across multiple payers
  • Improving cash flow through RCM
PROJECT CHALLENGES

Increasing Operational Efficiency across All the Regional Hospital Facilities

During an audit across the client’s hospitals and outpatient facilities, our team identified certain variations, revenue cycle bottlenecks, and areas of inefficiency. To identify gaps, we also evaluated the client's existing technology infrastructure, including electronic health record (EHR) systems, coding tools, and claims management solutions. Here’s what we discovered-

  • Some hospitals took up to 14 days on average to submit claims
  • Denial rates fluctuated between facilities from 10% to 45%
  • The organization processed an average of 2500 claims per week, 38% of which were backlogged, causing delays in reimbursement
  • Coding errors were identified in 15% of submitted claims
  • The average denial resolution time across facilities ranged from 21 to 35 days
  • Only 60% of the facilities were integrated into the central EHR system.
  • The organization faced an estimated $2 million in annual revenue leakage due to missed charges, under-coded services, and unbilled procedures
  • Inefficiencies in the RCM process contributed to an estimated $2 million in additional annual operational costs
OUR SOLUTION

Implementing a Comprehensive RCM Solution for Hospitals

Considering these challenges, we determined the following plan of action-

  • Consolidate various EHR systems across all the hospitals and outpatient facilities
  • Implement a unified protocol for claim submissions across all facilities to reduce the time variation
  • Enforce standardized medical coding and billing practices
  • Address and resolve denied claims across multiple payers to reduce the backlog
  • Clear the existing backlog of claims and then implement process improvements to prevent such backlogs
  • Handle related healthcare back-office operations
SOLUTION IMPLEMENTATION

Here’s How we Increased the Operational Efficiency for our Client

Dedicated Team AllocationDedicated Team Allocation

The team assigned to this project comprised 20 members, including project managers, RCM specialists, medical coders, record indexing associates, claim denial experts, and data analysts. The team was organized into several sub-teams to handle different aspects of the project efficiently:

  • Project Management Team
  • RCM Team
  • Process Optimization Team

Data annotation iconEHR/EMR Integration

We merged various EHR/EMR systems into a unified platform, ensuring consistent data across all facilities and allowing different systems to communicate and exchange information efficiently. This ensured patient data was accessible in real-time, regardless of the facility. The team handled data migration, cleansing, and enrichment where needed to eliminate duplicate, outdated, or incorrect records and maintain data integrity.

Unified Claim Submission ProtocolUnified Claim Submission Protocol

We followed a proven workflow for the claim submission process. This included predefined timeframes for each stage of claim processing, from patient registration to final submission. Automation tools were also introduced to handle repetitive tasks, such as data entry and initial claim scrubbing, reducing manual effort and errors.

Standardized Medical Coding and Billing PracticesStandardized Medical Coding and Billing Practices

To address the error rate in submitted claims, our RCM specialists conducted comprehensive audits of coding practices at each facility, identifying common errors and discrepancies. Then, we established a unified coding manual aligned with industry best practices and this client's payer-specific requirements. Our team used this manual to streamline the hospital billing process. A coding quality assurance team was also appointed to perform regular audits, provide feedback, and ensure adherence to standardized coding protocols.

Denial Appeals and ManagementDenial Appeals and Management

We aligned specialized resources within the RCM team to focus on denial management, responsible for promptly addressing and resolving denied claims. The team also implemented an automated tracking system to monitor denial trends, flag recurring issues, and ensure timely follow-up. The team first cleared the backlog and then moved on to timely denial management.

Data management iconProcess Improvement

To prevent future backlogs, we created a plan that prioritized high-value and high-impact claims to improve cash flow quickly. A continuous improvement framework was also set up to regularly assess and refine processes, ensuring sustained efficiency in claim submission and denial management and for enhancing hospital revenue capture.

Project Outcomes

Achieved 100% integration

Achieved 100% integration of all facilities into the central EHR system

Average claim submission time reduced to 7 days across all Facilities

Average claim submission time reduced to 7 days across all facilities

Denial rates reduced

Denial rates reduced to below 10% across all facilities

denial resolution time

Average denial resolution time reduced to 10 days

cleared the existing backlog

Successfully cleared the existing backlog of unsubmitted claims

coding and billing errors

Medical coding and billing errors reduced to below 5% across all facilities

Data annotation icon

Estimated annual revenue recovery of $1.5 million within 8 months

operational costs

Reduced additional operational costs by 35%, as monitored over a year

Contact Us

Get a Free RCM Consultation for your Healthcare Organization

As healthcare systems expand in complexity and scale, the pressure of revenue cycle management (RCM) in hospitals and independent practices intensifies. Our HIPAA-certified healthcare revenue cycle management services, claim management services, and denial management solutions take over that load so you can focus on patient care and make better financial decisions.

Schedule a free consultation with our RCM experts.

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