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  • Writer's pictureEffy Healthcare

How a Health System Overcame Authorization Denials to Collect More Revenue

Updated: Sep 21, 2020

Like many organizations, Bon Secours Health System had grown over the past several years and acquired may disparate revenue cycle processes and systems. In 2017, Rebecca “Becky” Crytser, MS, RN, CHRI, CPC, the Administrative Director of Revenue Integrity, was part of a team tasked with rectifying authorization challenges in the Outpatient Infusion Center (OPIC).

The problem was clear: claims were denied for missing/lack of authorization for infusion treatments, costing Bon Secours precious revenue and creating stress for patients. The solution was not as straightforward to identify. Even after working extensively with clinicians and optimizing their core EMR EPIC, Crytser and her team continued to be plagued with denials in the following three situations:  

  1. When there was a deviation in the care plan, or “add on therapy at the time of service,” which is common when treating cancer patients. Often, the adjusted treatment runs over authorized limits or includes a new drug.

  2. Authorization exceeding dosage amount.

  3. Despite excellent authorization and pre-certification processes already in place, occasionally services somehow got through the system. 

In summary, their processes could not identify missing or expired authorizations, or authorizations that no longer applied, in real time on the day of care. Unmistakably, time sensitivity was the key to success.

The challenge of finding the right solution

The revenue cycle leadership team evaluated several vendors.  They needed a tool that would  optimize their EMR, EPIC, work across their enterprise and operate in tandem with their existing technology and software. 

Crytser commented, “In my role, I could see what needed to be done, but couldn’t find the tool to do it. What I found most frustrating about our exploration process was that vendors would come in and tell me what they could do. What we really needed was for someone to listen to us and ask us what we needed.”

“Effy’s approach was completely different,” Crytser continued. “They listened and said they would create what I wanted. That got my attention! After I learned more about RAID Healthcare Business Assurance and saw how it could gather data, detect deviations, issue alerts and then guide the ‘fix’ with an integrated workflow, I knew it would be the best solution.”

According to Crytser, the bespoke technology to combat authorization denials was the primary driver behind the decision to move forward; but she cites two additional reasons why the Bon Secours team moved ahead:

  • RAID is a proven technology outside of healthcare that has a long, successful track record with complex and sensitive data with state-of-art security;

  • There were no high, up-front acquisition costs; RAID technology would fine-tune their existing RCM system – so it fit within their budget.

A collaborative approach to authorization denials

The first order of business for the team was ensuring valid authorizations for treatment. Leaders identified seven critical rules that guided authorizations for infusions and set the RAID technology to monitor CPT charges. Any deviation from the customized rules triggered a RAID Healthcare Business Assurance system alarm, set to recognize factors such as no authorization, authorization period, number of services, authorization expired, and usage exceeded. Since the alarms happen in a timely matter, the staff was notified about any breached rule or when authorization was nearing its limit or expiration date and could take corrective action.

The results: clinical excellence, prompt reimbursement

The system was so successful that it expanded from the Virginia market to Bon Secours' entire system within three months. Crytser explained the road to success, “Put simply, Effy Healthcare listened to us and succeeded in what they said they would do. RAID Healthcare Business Assurance filled all the little gaps that our other software could not. Our results quickly demonstrated proof of concept, and it was exciting to watch non-authorization denial rates fall and revenue increase.”

Effy Healthcare’s results for Bon Secours included:

  • Saved time and labor from streamlined back-end processes

  • Improved documentation, leading to more accurate coding

  • Efficient workflows that accommodated treatment changes

  • A decrease in A/R days due to increased clean claim rates

  • Millions of dollars in captured revenue that would previously have been authorization denial write-offs

Crytser summed up the experience of working with Effy Healthcare by saying, “Our whole team was delighted when it worked so effectively against non-authorization denials. It was a win-win. Patients were getting the care they needed while avoiding the stress of denied claims, and we were able to collect funds for treatments rendered promptly. It was soon clear how RAID Healthcare Business Assurance could be applied in multiple situations, from the revenue cycle to clinical quality controls. They truly empowered us to reach our goals.”

About EFFY Healthcare

Effy is a software and solutions house, with footprint in multiple markets, focused on improving efficiency in the healthcare industry through technology and driven to produce measurable results through RAID® Healthcare platform, a powerful actionable analytics software solution that addresses effectively all business assurance requirements: revenue, clinical, quality and operational to improve performance throughout healthcare organizations.

EFFY empowers hospitals, hospital systems and Integrated Delivery Networks (IDNs) to retrieve, review and compare massive amounts of operational, clinical and financial data across their total enterprise -- no matter the size, data incompatibility or platform complexity. Using customizable, exception-based triggers to identify deviations from norms, users can reduce errors and denials, improve efficiency and productivity, meet compliance requirements, and ensure financial viability.

Contact us today to learn how we can help your organization.


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