An East Coast-based, non-profit health system faced significant revenue loss due to underpayments. Without the proper financial analytics and reporting systems, the organization struggled to identify and address these revenue shortfalls.
AGS Health was contracted to provide accounts receivable services with a focus on identifying and recovering underpaid accounts using data analytics across multiple facilities.
Challenge
- Revenue leakages through unidentified underpaid accounts.
- Unavailability of financial metric comparison.
- No tracking of complex financial metrics across multiple reports.
Solution
AGS Health created a reporting system that analyzes payer contracts using a Structured Query Language (SQL)-based reporting model. The model incorporates a unified rule framework that considers various metrics, such as reductions for Medicare Low-Utilization Payment Program (MLPs), multiple procedure logic, and modifier impacts, to determine Current Procedural Terminology (CPT) rates. It then automates the reconciliation process by comparing the Explanation of Benefits (EOB) allowed amount with the rates calculated by the SQL model to identify potential underpayments by the payer. Finally, the system generates digital Power BI dashboards and reports that provide insights into underpayment analysis and the potential scope for lost revenue recovery.
Discovered $220K+ recovery scope for one year
~204K CPT codes reviewed within 2 months
99k+ underpaid claims identified
