Texas-based Pain Management
Group Improves Its Clean
Payment Rate with
End-to-end RCM Services
The Client
The client is a well-established pain management group with over 250 practitioners involved in acute and chronic pain management of patients in Texas.
Business Challenges
Improving operational margin is imperative for healthcare practices to thrive and sustain, but it’s difficult with the shifting reimbursement models like value-based care and ever-changing payor guidelines
Like the other practice groups in today’s healthcare climate, the client faced multiple difficulties, such as low pay despite holding the second-highest number of cases amongst the practices in Texas. There was an impediment to overall collections — threatening dissatisfaction with the services of the billing office because of the obscurity around RCM performance and any holistic strategy
And incomplete and inaccurate authorizations triggered denials which spiraled into more delays, and there was almost always a lag before someone got to it, which meant delayed resolution, if any.
Solutions Delivered
Facing declining cash flow, tighter margins, and inaccurate claims filing, leaders at the pain management group acknowledged they needed a revenue cycle transformation and approached revenue cycle management (RCM) experts at Jindal Healthcare. We broke down these complex sets of interrelated challenges into smaller segments to provide a comprehensive denials management and authorization & verifications solution for our partner.
We utilized our in-house proprietary AI tool, HealthX to analyze denials rate. We then applied Pareto principle to figure out the biggest impact area. We found that almost all office visits requiring authorization were denied, a ” whopping 72% of the claims”. This was a little unusual since payers generally don’t require prior-auth for office visits.
With a round of phone calls and isolating the denied cases, we identified that all these cases belonged to a particular plan product – BCBS health select. While the group’s BCBS PPO claims would be processed without an issue, BCBS health select needs authorization or referral. This is a serious concern — as per the 2021 American Medical Association study, 18 percent of physicians report that prior authorization delays have led to “life-threatening” events, and 34 percent say that prior authorization issues have led to “serious adverse events” for a patient in their care. We immediately alerted the verification team to create a flag and complete the authorization process for any new BCBS health select patients before they are seen.
Another challenge was that the payer claimed to not have received the NDC information requisite for medication codes on the electronic claims; they were, however, added to the patient’s account in the CRM software.
Although the medication allowable was quite small, the sheer volume meant huge claims stayed in the red. We couldn’t bill the patient for their coinsurance/deductible on the other codes unless this gets resolved. While we ensured that all affected claims were re-submitted on the web portal with requisite information instead of dropping paper claims. To make sure this doesn’t continue in the future, we made a round of calls with the CRM support team and the payer provider relations to realize that the information needed to be filled in a different section of the software to allow the electronic claim to verify and pick it.
Outcomes
goes down by
98%
up by
40%
in less than 6 months.
Increase in staff utilization by
