Background
ProHealth Care, a health system located in southeastern Wisconsin with two hospitals, seven urgent care centers, and 14 clinics, was in need of a solution to handle denials – its biggest reason for revenue cycle underperformance. With payers constantly changing their requirements, and in some cases automating denials, providers often felt overwhelmed trying to keep up. Without meaningful analytics, they struggled to identify the root cause of denials and were unable to take corrective action, even on denials that could have easily been prevented. The result was high A/R days, too many write-offs, and sluggish cash flow.
Thanks in large part to denial analytics within RCM Intelligence, revenue cycle leaders at ProHealth were able to quickly address the root cause of denials and improve financial performance.
“When you have access to information, like the denial dashboards we see every day from RCM Intelligence, we can get on top of things right away.”
”If you have the relevant data coming through from a good system, you can use that to identify and address issues. Not at the end of the month, not at the end of the week, but on a daily basis.”
Curt GlaunertVice President of Revenue Cycle at ProHealth Care
Upgraded Platform Delivers Actionable Insights
“The dashboards are very interactive, making it easy to drill down to get to the information you need from a denials standpoint. Whether it’s denials, edits, or overall performance, RCM Intelligence’s tools have helped us spot trends and make decisions that keep us moving forward,” Glaunert said. “They developed a truly powerful analytics platform at Inovalon.”
RCM Intelligence allows organizations to develop feedback loops that increase revenue cycle efficiency. In ProHealth’s case, RCM Intelligence’s denial reports show leaders if they need to make adjustments upstream in the revenue cycle. If the system indicates high initial denials for eligibility, it could mean that patient access team members are not gathering the right information at time of registration. In this way, RCM Intelligence opens lines of communication between the revenue cycle and other departments to promote greater understanding and additional denial education.
”With the information available to us, we can go to the front-end and use it to help identify and correct problems. We work with our front-end teams and others who don’t necessarily report to the revenue cycle, and we have the facts behind us through solid analytics to adapt to issues quickly.”
With Analytics Included, Providers Save
Costly, standalone analytics platforms claim to give users actionable insights and intuitive dashboards. ProHealth had previously used an analytics tool that cost almost $500,000 a year. It had many of the same capabilities as RCM Intelligence, but it had integration issues due to how data was able to be extracted. At far less than $500,000 annually, RCM Intelligence provides the right mix of tools to help revenue cycle teams manage their denials more effectively.
“We reduced our cost significantly – hundreds of thousands of dollars – just by eliminating that platform,” Glaunert said.
”RCM Intelligence is one of the top systems I’ve ever worked with in regard to having the data and tools at your fingertips to solve root-cause issues.”
Proven Results: Clean Claims Up, Denials and Write-Offs Down
Thanks to RCM Intelligence’s analytics and the resulting process improvements, ProHealth has seen impressive results. Industry statistics show an average of 20-25% of claims rejected on first submission. ProHealth routinely achieves 90% to 95% of claims paid on first submission. Their high first-pass yield rate helps the organization consistently keep its A/R days in the 30s.
ProHealth’s denial metrics are similarly remarkable. Its overall denial rate is less than 5%. With that low rate, its write-offs as a percentage of net revenue are less than 1%. This level of success would not be possible without RCM Intelligence’s analytics.
“A lot of our success at ProHealth Care is due to the fact that we’re linked up with RCM Intelligence,” Glaunert said. “I worked in revenue cycle consulting for 20 years before I came to ProHealth Care. I’ve worked with a lot of different systems and RCM Intelligence is one of the top systems I’ve ever worked with in regard to having the data and tools at your fingertips that can be used to solve root-cause issues.”
”They developed a truly powerful analytics platform at Inovalon.”
ProHealth routinely achieves 90% to 95% of claims paid on first submission.
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1 Inovalon calculation based on HEDIS® MY2022 data. September 2023
