Driving Impact
Revenue Management Engagements
Regional ENT Practice
Mission and goals
The engagement was focused on assessing the in-house RCM performance and designing the improvement projects focused on. The engagement expanded an interim RCM position and further engagement with clinical operations :
Goal 1: Assess performance of in-house RCM & determine process, technology, and staffing opportunities.
Goal 2: Analyze denials to determine prioritize largest opportunities.
Goal 3: Map patient journey to determine conversion opportunities (multi-visit patient appts).
Goal 4: Create actionable dashboards and KPI’s of baseline performance and “to be” performance.
Project items and details
Engagement started with performance assessment of the in-house billing. Pulled transactional data for 2+ years to generate a performance baseline. Analysis identified opportunities in revenue leakage, and payor & patient yield.
· Phase two of the engagement is focused on;
Development of actionable KPI’s in weekly/monthly operating and executive dashboards.
a redesign of the insurance verification & authorization processes.
Audit/update of fee schedules & design of underpayments process & team
Redesign of patient contact 3rd party vendor to increase patient education and overall patient yield.
ROI & Impact to date
Weekly & monthly dashboards are automated and being used in management weekly meetings. Insurance verification and authorization processes re-designed and in stable operation. 3rd party vendor launched to improve patient contact via multi-modal communication channels driving material increase in yield.
Key metric improvements:
1st Pass Claim Adjudication improved to 94% (claims paid without further action)
Actionable denials reduced to <1%
Patient yield improved to 80%+ (collections vs owed)
Write-offs reduced by 3x
Behavioral Health RCM & Insurance Advocacy
Mission and goals
The engagement was focused on assessing the claims and denial management of Inpatient, PHP level and outpatient levels of care for several long-term Residential Treatment Centers
Goal 1: Assure Medical Necessity is met through coding and clinical documentation process.
Goal 2: Improve Denial Management and follow up by developing and implementing timely review and claims dispute process.
Goal 3: One-off insurance advocacy for difficult payors (develop case by case strategy’s)
Length of Engagement: 13 months
Project items and details
Engagement started with performance assessment of the in-house denials management. Reviewed payor denials for 12-month period, focus primarily on Kaiser Permanente OON. Analysis identified opportunities in revenue leakage and payor yield.
Phase two of the engagement is focused on redesign of the denial follow up and dispute process. Focus areas included clinical documentation, coding, and timely filing.
One-off insurance advocacy converted multiple long term (>8 months each) self-pay into 100% insurance pay yielding 3x in revenue (both in/out of network plans).
ROI & Impact
The engagement resulted in redesign of the denial & follow-up processes. The engagement also enhanced documentation to support medical necessity. The engagement led to over an 8x return in self pay conversions to insurance pay in the 5 patient advocacy engagements ($1.25M revenue lift).
National Home Infusion Group (Specialty Pharmaceutical)
Mission and goals
The engagement was focused on assessing the in-house RCM performance and designing the improvement projects focused on:
Goal 1: Assure 100% charge capture of both the drug and Per Diem billing
Goal 2: Improve RCM effectiveness by designing & automating verification, billing and collections queues to focus on the highest value accounts as well as creating a payor playbook that institutionalizes payor rules by sub-plan and group
Goal 3: Analyze the fees charged vs 835 data to maximize the revenue and minimize adjustments
Length of Engagement: 12 months
Project items and details
Engagement started with performance assessment of the in-house billing. Pulled transactional data for 2+ years to generate a performance baseline. Analysis identified opportunities in revenue leakage, and payor & patient yield.
Phase two of the engagement is focused on redesign of the insurance verification & authorization and collections processes. Process queue are being designed to auto-populate the work queues of the teams leveraging the highest valued/risk accounts (risk based queueing theory). Additionally, SQL applications have been created to find any missed charges so delivery tickets could be generated. Finally, phase 2 also includes the 835 analysis against the fee schedules to determine fee schedule accuracy.
ROI & Impact
The engagement led to redesign of RCM follow-up work queues and reducing no-authorization denials Additionally, improvements in charge capture and fee schedules have also increased net revenue. Based on leakage analyzed in phase 1, improvement exceeded $9MM. Total engagement ROI exceeded 36x over expenses.
East Coast Physical Therapy Group
Mission and goals
The engagement was broken into three phases with the goal of improving the RCM performance measured by patient/payor yield.
Phase 1: Assessment of current vendor performance
Phase 2: Project managing the implementation of the new solution and achieve ROI
Phase 3: RCM vendor improvements
Length of Engagement: 24 months
Project items and details
Engagement started with performance assessment of current RCM vendor. Pulled transactional data (>10M charge id’s) for 2 years of incumbent RCM performance as baseline. Analysis identified opportunities in both payor and patient yield.
Phase two of the engagement focused on the RCM transition to a vendor selected by the company. The transition was completed on time and did not impact the POS EMR.
The third phase of this engagement is focused on improving the performance of the vendor selected. Limitations in the RCM vendor required moving the data into Tableau to generate the data insights required to achieve the RCM targets. Additionally, the data insights generated are used to direct improvements to both performance as well as processes in the RCM vendor.
ROI & Impact
The engagement resulted in changing RCM vendors and working with the new vendor to develop reporting (including but not limited to denial reporting that did not exist at that vendor).
Midwest Physician Group (~100 Docs)
Mission and goals
The engagement was broken into three phases with the goal of improving the RCM performance measured by patient/payor yield.
Phase 1: Assessment of current vendor performance
Phase 2: Identify and develop a comparative analysis (ROI) of alternative RCM solutions
Phase 3: Project managing the implementation of the new solution and achieve ROI
Phase 4: Physician compensation modeling / Vendor analysis of acquired groups
Length of Engagement: 14 months
Project items and details
Consulted with large physician practice. Engagement started with performance assessment of current RCM vendor. Pulled transactional data (>13M charge id’s) for 2 ½ years of incumbent RCM performance as baseline. Analysis identified opportunities in both payor and patient yield.
Phase two of the engagement included doing a comparative analysis of; two other RCM vendors, fully insourced RCM model and a hybrid RCM model that included utilizing a vendor for some aspects of RCM. The comparative analysis showed an improvement in performance between $2MM to $5MM based on the option chosen.
The third phase of this engagement was the launch of the hybrid model that included implementation of a new RCM vendor and design/build of a coding and patient contact center to maximize the patient/payor yield. The implementation was completed ahead of schedule and under budget.
ROI & Impact
The engagement resulted in changing RCM vendors and creating a hybrid RCM model that utilized a new RCM vendor for most payor related functions and an inhouse RCM solution to manage patient contact. The engagement also resulted in changing 3rd party patient agency. The engagement had a 12-month ROI of 18x over expenses.
Southern based Physician Group (~200 Docs)
Mission and goals
The engagement was broken into an assessment phase and projects focused on improving in-house RCM performance (primarily patient yield).
Length of Engagement: 15 months
Project items and details
The consulting focused on the in-house revenue cycle management (RCM). Utilizing historical transactional data sets in conjunction with descriptive techniques and predictive models to extract information and identify improvement opportunities of the “as is” performance. Payor and patient yields were calculated, and statistical drivers of performance variance identified.
Detailed project sets focused on process re-design of the patient contact strategy, creation of propensity to pay models utilizing past payment patterns and third-party data, technology implementation to drive efficiency, payor pre-service exemption-based authorization process and payor follow-up and denial management process re-design utilizing risk-based queuing theory.
ROI & Impact
The engagement resulted in improving patient yield for both pure self-pay and patient liability after insurance yields. Payor performance variance was also reduced by improving follow-up and denial management work queues. The engagement had a 12-month ROI of over 12x over expenses.
West cost based Physician Group (~200 Docs)
Mission and goals
Consulting engagement with large physician group focusing on a 6-Sigma workflow process re-design of the patient contact center, insurance billing and medical coding quality assurance functions.
Length of Engagement: 15 months
Project items and details
The consulting engagement focused on utilizing historical transactional data sets to quantify “as is” performance.
Engagement focused on workflow re-design of the patient contact center and the creation of a patient contact strategy that leveraged propensity to pay predictive models
In Addition, a risk-based billing queuing model leveraging past payor transaction history to create billing priority and determine the probability of re-bill success based on denial and historical payor patterns.
ROI & Impact
The engagement resulted in improving both patient and payor yield. Clean claim rate improved 4% and patient yield improved by over 10%. The engagement had a 12-month ROI of over 16x over expenses.
Large Midwest Healthcare system (~$2B Patient Net Revenue)
Mission and goals
Partnered with large mid-west healthcare system on designing and implementing a standardized pre-arrival financial clearance center with the focus of increasing clean claim rate and reducing authorization denials.
Length of Engagement: 12 months
Project items and details
Reengineered the insurance authorization process to be exemption based which increased staff effectiveness and improved percent authorization obtained by allowing staff to focus only on the encounters that required authorization. Designed, built and maintained exception-based authorization table driven by payor/CPT codes. Worked with EMR vendor to transform tables into business rules to drive the authorization work list.
Led staffing analysis and designed department structure for six facilities into the centralized center.
Acted as intermediary between client operations, Information Services and Siemens during the development and troubleshooting of department work lists and reports within Siemens Soarian.
Partnered with individual facilities to document “as is” process flows and created optimized workflows. Collaborated with departments to ensure best practices were integrated into “to be” processes.
ROI & Impact
The engagement resulted in improved efficiency of the pre-service and point of service teams and reducing authorization denials by 1/3 driving up patient yield and improving the efficiency of the billing and denial management team. The engagement had a 12-month ROI of over 14x over expenses.
Nonprofit family planning system (~$1.3B Patient Net Revenue)
Mission and goals
Supported national non-profit family planning organization in efforts to drive operating efficiencies by re-designing billing and follow-up processes. Additionally, worked with technology vendor and client teams to optimize the client’s technology platform to streamline staffing and increase productivity.
Length of Engagement: 4 months
Project items and details
Rebuilt EMR Reason Code library to support multiple payors denial codes and streamline auto-posting.
Designed, built and implemented employee work lists prioritized by payor and denial type to improve efficient in follow up process.
Segmented payor posting among cash posting team and setup NextGen auto-posting capabilities for HL7 feed compatible payors.
ROI & Impact
The engagement Improved days to bill from 12 to 4 days and improved days to post from 14 to 100% posted within 3 days. The engagement had a 12-month ROI of over 7x over expenses.
Midwest academic medical center (~$1.1B Patient Net Revenue)
Mission and goals
Partnered with respected Academic University Medical Center in Midwest to increase operating efficiencies and revenue capture pre and post service through process redesign and vendor assessment.
Length of Engagement: 11 months
Project items and details
Charged with establishing Patient Access departmental structure, process flow and staffing model to ensure optimal productivity. Establishment of departmental policies and KPI reporting.
Developing implementation plan for new EHR system, incorporating Insurance Verification, ABN Identification, and Price Estimation.
ROI & Impact
The engagement resulted in improving patient access efficiency and effectiveness and reducing authorization denials. The engagement had a 12-month ROI of over 18x over expenses.
Southern based 3rd party RCM Vendor
Mission and goals
Consulted with large third-party RCM company providing operational assessment of operating performance. Follow-up project focused on utilizing past payment patterns to create predictive models as the foundation of the patient contact strategy.
Length of Engagement: 7 months
Project items and details
The consulting engagement focused on utilizing historical transactional data sets quantify “as is” performance. Payor and patient yields were calculated, and statistical drivers of performance variance identified.
Follow-on project focused on utilizing past payment patterns to create predictive models. This patient propensity to pay models utilized historical data as well as 3rd party data sets to identify who to call when based probability of payment and receptivity of channels of communication. These models were used as the foundation of the patient contact strategy.
ROI & Impact
The engagement resulted in improving patient yield for both pure self-pay and patient liability after insurance yields. The engagement had a 12-month ROI of over 17x over expenses.
Global leader in CPG (~$1B Revenue)
Mission and goals
Working with global leader in the consumer-packaged goods (CPG) and retail industries that supports over 95% of the global fortune 500 in CPG and retail providing big data analytics consulting.
Length of Engagement: 18 months
Project items and details
Using many years of retail scanner data, group panel data and third party socio-economic data created advanced analytic sets to create predictive models that are utilized to support top 100 clients
Models focused on predicting new product adoption curves, out of stock predictions and predictive modeling of product placement.
ROI & Impact
The engagement resulted models that were used in new engagements by CPG manufacturers.
R1 RCM
R1 (BPO outsourcing) 2005 -> 2012.
Senior Vice President – BPO Shared Service Operations
Grew shared service revenue from start-up to $350MM in annual revenue in five years.
Created first shared service center from concept to over 100 FTE in first year and growing to more than 500 FTE in multiple locations worldwide. Designed processes, technology and the operations culture utilizing Design for Six Sigma processes.
Consolidated multiple shared service centers by moving the initial center to Kalamazoo MI to increase scale, reduce rooftops and create an end to end revenue cycle management strategy that encompassed pre-service registration, insurance verification and post service patient contact and insurance billing. Team expanded to over 500 blended shore employees creating one touch solution for over $15 Billion in annual net patient revenue.
Grew patient liability recovery from $2MM in 2006 to over $130MM in 2011 with continued growth in organic collections - 20% 2010 v 2011 on a 1% change in organic volume and has grown an additional by 31% ($6.6MM) Q1’11 v Q1’12.
Insurance (re)billing of over $100MM in 2011 based on post service patient contact with an additional $70MM in presumptive charity (based on proprietary predictive models) prior to placement to bad debt.
Productivity increased 79% in cash posted per call attempt and 32% in cash posted per contact ‘11 vs ‘10.
Pre-service insurance authorization levels consistently exceeded 98% using Six Sigma designed exception-based workflow processes.
Data Science and predictive models
Created best in class predictive models (patent pending) synthesizing multi-terabyte data warehouses that drove patient lift predicting capacity and willingness to pay models. Created strategy and models leveraging 15+ years in the area of model design and diagnosis, data mining, data analysis, decision support solutions and reporting in Technology, Healthcare and Financial industries.
Created unique differential segment treatments of up to 30 nodes that factor in demographic data, past payment pattern data in combination with socio-economic data to create homogeneous market model. The AH Score has outperformed numerous third party national models in champion vs challenger studies.
Created representative skill matching to patient contact analytics model to maximize customer experience and yield.