INDUSTRY Case Studies
See how Integrex RCM solutions help clients with streamlining time consuming processes and achieve payer specific data alignment that corrects inaccurate demographics.
Insurance Discovery
Client:
RCM Firm Specializing in Pathology
Challenges:
- Incomplete demographic information provided by hospital
- Time consuming process to verify insurance coverage for self-pay accounts
- Insurance coverage received from outside provider entities incomplete or policy termed
Solutions:
- Daily process validates self-pay accounts for insurance coverage
- Ability to validate Insurance coverage received from outside provider entities
- Medicaid, Managed Care and Commercial payers prioritized and cascaded
- Payer specific data alignment corrects inaccurate demographics
Results:
- 40%+ average success rate locating active coverage
- Validation process created higher clean claim rate which also resulted in higher net collection rate
- Integrated Integrex RCM API in NextGen as a process upgrade to uploading and downloading files
Client:
National Wound Care Provider
Challenges:
- Incomplete demographic information provided by hospitals
- Unnecessary outreach to patients for collections
- Time consuming process to verify insurance coverage for self-pay accounts
Solutions:
- Weekly process validates self-pay accounts for insurance coverage
- Government, Managed Care and Commercial payers are prioritized and cascaded
- Payer specific data alignment corrects inaccurate demographics
- Medicare verification without SSN or MBI
Results:
- 44% average success rate locating active coverage over 12 months
- Accelerated time to revenue with comprehensive solution that enters and submits claims in Practice Management System
- Reduced cost of outreach to patients
- Identification of Blue plans in 40+ states that had previously required an intensive, manual process to validate coverage
Client:
Radiology and Imaging Firm
Challenges:
- Incomplete demographic information provided by imaging centers
- High volume low dollar procedures required a creative financial model for insurance discovery
- Time consuming process to verify insurance coverage for self-pay accounts
Solutions:
- Weekly process validates self-pay accounts for insurance coverage
- Medicaid, Managed Care and Commercial payers prioritized and cascaded
- Payer specific data alignment corrects inaccurate demographics
Results:
- 33% average success rate over 18 months locating active coverage with a 3X return on spend
- Accelerated time to revenue with comprehensive solution that automates entering and submitting claims in Practice Management System
- Identification of Blue plans that had previously required an intensive, manual process to validate coverage
Client:
RCM firm working with a network of hospitals, clinics and home care services in 5 mid-western states
Challenges:
- Inefficient and expensive process for contacting patients to capture insurance information
- Shortage of resources to review entirety of benefits information to enter and submit claims in a timely manner
Solutions:
- Daily process validates accounts for insurance coverage, including hard to locate blue plans and Amerigroup
- Customized output file captures relevant policy information required to enter and submit claims
Results:
- 30% average success rate over a 6 month program
- ROI includes 2.5X return on spend along with more efficient use of resources
Client:
13,156 accounts with Medi-Cal indicated as the payer
Challenges:
- Determining if other payers are primary
- Identifying MCOs, IPAs and / or Medical Groups on policies
- Correcting incorrect patient first names, last names and dates of birth
- Identifying coverage for incorrect Medi-Cal member IDs
- Accelerating delivery of accurate information for proper claim submission
Results:
- 965 rows had incorrect Medi-Cal member IDs that did not conform to the Medi-Cal member ID convention. Our Demographics Enabler was able to utilize 617 of the 965 rows. We returned 465 rows with active coverage.
- Uncovered Managed Care Organizations and / or IPAs and Medical Groups for
Medi-Cal with 8,397 rows of which all have active coverage. - We identified SSNs for 9,491 rows and corrected 2,915 rows with names and / or dates of birth, both of which contributed to 10,959 total rows in the file with active results.
- 1,235 accounts were outside of the date of service range to check Medi-Cal eligibility. The payer responded as follows: “Enter an as of date up to 12 months in the past and to the end of the current month.”
Claim Status
Client:
Radiology and Imaging Firm
Challenges:
- Numerous phone calls to Anthem with transfers to other state plans for claim status resulted in low utilization of denial team
- Issues coordinating claim resolution with in state and out of state plans
- Length of time to work and resolve claims
Solutions:
- AI Pattern Analysis detected and corrected inaccurate patient and plan information in the inventory file
- Anthem Prefix Finder API indicated if member belonged to an Anthem state plan
- Additional claim adjudication detail resolved the mystery of missing documentation that resulted in a denial
Results:
- 5,219 out of 5,300 claim status requests returned successful responses
- 88% call avoidance
- Performance of denial team extended claim management engagement by 6 months
Client:
Radiology and Imaging Firm
Challenges:
- Data integrity issues with provider inventory file prevented full scale automation
- Allocation of accounts was inefficient due to lack of details regarding the current status of claims
- Contingency relationship between RCM firm and its client required extremely efficient resource utilization
Solutions:
- AI Pattern Analysis detected and corrected inaccurate patient and plan information in the inventory file
- API connectivity to claims data accelerated processing time of claim status requests
- Auto suggestions reinforced data handling to improve claim status success rate
Results:
- 7,204 out of 7,500 claim status requests returned successful responses
- 90% call avoidance
- Performance of denial team led to additional engagements for resources and technology services
Client:
RCM firm working on behalf of southeast health system with 1,000+ beds
Challenges:
- Excessive number of phone calls and web lookups to obtain claim status
- Incorrect patient information including member ID
- Implement touchless transactions to reduce labor costs
Solutions:
- Delivered Extended X12 Claims Data for major payers like Anthem BCBS (14 states), Humana, United Healthcare and others to avoid phone calls and web lookups
- AI Pattern Analyzer detected and corrected inaccurate patient information that otherwise would have led to unsuccessful claim status responses
- Trigger response mechanism placed accounts with certain statuses in a future work queue
Results:
- Depth of claim adjudication information includes allowed amount, patient responsibility and actionable denial descriptions, which creates a framework for touchless transactions
- Successful claim status response rate increased by 25%
- Eliminates current touches and focus labor on resolving high value claim denials
