Innovative RCM Strategies helped Healthcare Provider to Exceed EBITDA Targets with AMI

The leadership team of a healthcare provider company, had a task at hand from their private equity investor to meet a specific EBITDA target within the next two quarters. The most effective and quickest solution identified while enhancing patient experience was to optimize their Revenue Cycle Management (RCM). They chose AMI as their ideal partner for this task after evaluating multiple vendors. The key factor in choosing AMI was because of their customized solution, specifically designed to meet their needs, along with their domain expertise, intellectual automation capabilities, and streamlined operations, significantly benefiting the provider in achieving their financial and operational objectives.

AMI helped the healthcare provider tackle their unresolved claims, resulting in decreased Accounts Receivables and enhanced resolution rates among other benefits.

The synergy of specialized knowledge, intellectual automation, and efficient operations significantly aided the provider in effectively addressing their challenges. Let us understand how that was possible.

CHALLENGES & SOLUTIONS

Challenge #1

Unresolved Claims - Our partners encountered challenges with unresolved claims in accounts receivable (AR) exceeding 90 days, comprising approximately $ 4.34 Million in unresolved claims that proved difficult to manage the operations with their internal team effectively.

Solution #1

In three months, we reduced the bucket of more than 90 days in AR from $ 4.34 to $ 3.25 million using effective communication tools, payer portals, and CRCS-certified AR leaders, enhancing efficiency and revenue cycle management.

Challenge #2

Underpaid Claims - Receiving lesser amounts in payments from payers than what the contracts stated.

Solution #2

In our preliminary review of settled claims, AMI identified over 1,700 inaccurately compensated claims, totaling more than $204,000. We coordinated with the provider relations team on the payer's end and, through ongoing communications, were able to recover underpaid claims.

Challenge #3

Net Collection Rate (NCR), First Pass Ratio (FPR), and Clean Claims Rate (CCR). - Their NCR, FPR, and CCR were less than 95% due to inefficiency in the implementation of the collection process and challenges in claims with huge outstanding balances.

Solution #3

We've maintained a steady 95% Net Collection Rate (NCR), First Pass Ratio (FPR), and Clean Claims Rate (CCR). This was achieved by effectively working on timely follow-ups, Maintaining rigour and working on rejections and denials establishing a communication grid between AR and other departments to ensure timely updates from AR being followed by the other departments.

Challenge #4

Sending Patient Statements and Collecting Balances - Incorrect process of sending patient statements. The patient collection process did not exist, and standard patient collection processes were not implemented.

Solution #4

From $700,000 to now less than $350,000 in inpatient collections within a span of 3 months, the team adhered to structured follow-up methods based on the Fair Debts Collection Practices Act (FDCPA).

Challenge #5

The Resolution Rate - The Resolution Rate of AR Collectors fell below 80%.

Solution #5

We helped them increase their Resolution Rate from less than 80% to now at 97% as we hired the associates with the necessary with the necessary CRCS certification by AAHAM. The associates followed the updated SOP rigorously with seamless communication with the payer counterparts.

Challenge #6

Referral and Authorization - With over 50% rejection ratio in the authorization and re-authorization of services. Resulting in burdening the patients.

Solution #6

Currently, with the robust protocols and process improvements in place, the rejection ratio has dropped from 50% to 10%. This was made possible by 100% live audits, which then was followed by real-time feedback and frequent training workshops for the associates.

Challenge #7

Quality Management System - The clients were lacking the Quality Audits aspect from their day-to-day operations.

Solution #7

Currently, with 99% accuracy, the quality of operations has reached to a better-optimized stage. We have adopted the DPO methodology for non-fatal defects and DPU for fatal errors.

Challenge #8

Denial Rate - The client faced a denial rate of over 43%.

Solution #8

Implementing 3 step disposition method to pinpoint the denial and its root cause which eventually helped in the reduction of denials from 43% to 10% in 2 months which is currently at 4%.