Bon Secours Mercy Health System, located in a largely urban area in the United States, needed to decrease authorization denials without incurring the costs of upgrading or replacing their existing RCM systems. After a long search, they came upon a new solution that could work with the systems they were already using – Effy Healthcare. Read more about how Effy virtually eliminated stubborn denials by filling in operational gaps between systems, and how they automated workflows for corrections that resulted in authorized treatments and more revenue.
The project’s overall goal was to ensure clinical and operational excellence while supporting the organization’s financial viability. Like many healthcare systems, Bon Secours Mercy Health had undergone significant expansion over the past few years. Every acquisition and new location generated massive sets of data that needed to be reconciled, reviewed and streamed into the claims generation pipeline. Disparate platforms and processes added significant complexity to RCM processes throughout the enterprise.
Identifying the issues
The team decided focus on the outpatient infusion treatment center and begin with authorization denials. Bon Secours knew that denials occurred primarily when there was a deviation in care, but the root cause was not straightforward; leadership had been working to resolve the issue for some time.
With the Effy team, they studied the path of every piece of information that was required for authorization and uncovered the root cause – a technology loophole. They discovered that although charges dropping on the claim were entered correctly into the existing operating system, the system failed to confirm payer authorization and the opportunity to obtain authorization was lost.
The investigation uncovered another area of deep concern: documentation for medical necessity. A change in health status needs to be expressed through accurate coding for the new treatments to be reimbursed by payers. A history of medical necessity denials indicated, and investigation confirmed, that staff needed to provide more comprehensive documentation to produce accurate coding that justified the change in treatment.
Introducing the Solution
Rather than having a ‘packaged’ program like so many other revenue cycle partners, EFFY offered Bon Secours a customizable, proven solution – RAID Healthcare Business Assurance (RAID). With RAID, they could create an umbrella over all existing systems and set alarms that would trigger anytime it identified a denial circumstance – making it possible to prevent denials before they happened.
RAID’s software platform is the established leader of Business Assurance technology for international telecommunications and used by the most prominent telecom companies worldwide to improve performance. Cellular and cable companies across five continents have depended on RAID software for many years. Since it is not an operational or transactional solution, RAID can be layered on top of any existing system. Effy enhanced RAID’s proven capabilities in telecom to launch RAID Healthcare, a platform unique to the health industry.
RAID Healthcare audits and continually examines behaviors to detect exceptions that impact the financial, operational, and clinical performance of healthcare organizations. The result of this collaboration is reporting, dashboarding, analytics, workflow management and variation alerts delivered through a single, real-time solution that streamlines decision-making, protects revenue and measures performance against KPIs.
Best news of all, especially to the CFO, was that EFFY and RAID Healthcare eliminated the need for large up-front acquisition costs, representing a financial transaction that would fall within budget.
“We really liked the fact that RAID was proven technology outside of healthcare,” expressed the leadership team. “The fact that complicated industries worldwide, such as telecom, rely upon its actionable analytics gave us an extreme level of comfort.”
RAID Healthcare proved to be a solution that over-delivered.
The team identified and triggered seven rules that governed authorizations and tasked the RAID platform to begin monitoring CPT charges. From the first day of go-live, circumstances that previously let to a denial were identified via real-time alarms and resolved. Since the team had already configured streamlined workflows to rectify alarms, corrective action was swift. The impact of authorized treatments was seen during the first claims cycle with an uptick in revenue. Within weeks, there was a dramatic drop in denial ratios and subsequent write-offs.
Hospital leaders quickly realized the corrective opportunities Effy and RAID provided to their organization and expanded the rule set to ten.
Results and ROI
The impact to Bon Secours’ revenue was dramatic. Savings related to denials and write-offs continue to accrue and have already exceeded millions for the outpatient infusion treatment center.
Within weeks of launching, the program was rolled out to other infusion centers in the network with equally impressive results.
Amazing ROI! The solution paid itself in first six months of use in one single service unit.
Streamlined back-end processes have relieved stress and time constraints imposed on the clinical staff. Inadequate or missing documentation of medical necessity has been addressed, allowing the hospitals to transition charges to patient self-pay or to initiate a change in of treatment.
Not only has there been an elimination of denials, but there has also been a decrease in days in AR because of higher clean claim rates.