With a robust revenue cycle, a large Texas not-for-profit health system faced challenges stemming from its high professional billing (PB) denial volume, significantly impacting collections and cash flow. Denials within the accounts receivable (A/R) inventory resulted in increased costs, frequent errors, and reduced efficiency.
AGS Health implemented a denial management project management office (PMO) to improve the health system’s denial management process by combining analytics, technology and a PMO resource to lead efforts and a collaborative approach with the client. Identifying root causes of denials and implementing targeted mitigation strategies significantly reduced denial volume, leading to improved operational efficiency and enhanced financial outcomes.
Opportunities
- Reduce high professional billing denial volumes across key categories by addressing recurring issues in coding, billing, and prior authorizations.
- Enhance pre-billing and coding accuracy and reduce inefficiencies and bottlenecks through targeted edits and automation.
- Improve cash flow by reducing denial-related operational costs and expenses incurred by the collections team to work and appeal denied claims.
- Empower teams with actionable insights through advanced data analytics.
Solution
- Analytics:
- Implemented a comprehensive denials dashboard to provide valuable insights into denial trends and analysis, empowering informed decision making.
- Root Cause Analysis:
- Collaborating with the client, the AGS PMO leveraged the analytics to perform root cause analysis and optimize resource allocation to expedite denial resolution.
- Collaboration on Denial Remediation:
- Recommended 35+ HIM edits for coding issues, including modifiers, CPT/DX reviews, and lab-related denials.
- Improved billing processes by resolving information gaps and attachment-related errors through pre-submission checks.
- Conducted training sessions for clinical and HIM teams to address authorization and billing challenges.
- Automation Solutions:
- Introduced automated adjustments for non-covered services to reduce unnecessary manual collections workload.
Outcomes
Reducing Denials
Reduced denials by $1 million over 10 months, including a 62% reduction in coding denials, a 40% reduction in billing denials, and a 64% reduction in authorization denials.
Operational Improvements
Improved coding accuracy and clean claim rates by collaborating with HIM and billing teams to improve cash flow and resource allocation.
Process Improvements
Established institutional processes for PB denial management by implementing PMO program, including a streamlined denial tracking and reporting dashboard to enable proactive decision-making.
