"We're likely to apply RAID Healthcare to multiple departments -- virtually anywhere and in any department-- even the most problematic areas."
In 2017 a large hospital system located in a largely urban area in the southeast United States sought a Revenue Cycle Management solution to effectively address challenges specifically related to the struggles with denials management, appeals and Medicare local market rules.
The overall goal was to ensure clinical and operational excellence while supporting the financial viability of the organization. The System had undergone significant expansion over the past few years, bringing massive sets of disparate data to be reconciled and reviewed, and significant complexity to RCM processes throughout the enterprise.
Identifying the Issues
Specific issues regarding treatment authorizations were particularly confounding, impacting the organization's ability to mitigate claim denials for treatments provided in the outpatient infusion therapy center.These occurred primarily when there was a deviation in the plan of care, burdening clinical and operational teams to secure authorizations for treatment necessitated by a change in the patient's health status.
Too often, these approvals were not processed with the payer for a variety of reasons. The claims were denied, even though the care was rendered and the expense incurred -- which led to a write off for the hospital system.
While the screens on the existing overall operating system registered the charges that would be dropping on the claim, it failed to confirm Payer authorization -- which often proved not to be forthcoming.
Another area of deep concern was documenting medical necessity in order to ensure reimbursement. Here again, the System was burdened with claim denials resulting from documentation failure.
EFFY - Powered by RAID Healthcare
Hospital leaders responsible for revenue cycle evaluated several vendor solutions which all promised to deliver results. Since they had already invested significant funds in an overall operating system and some analytic tools, they had no intention of discarding the operating system and replacing it with a different and equally expensive transaction-based model.
Many vendors touted their product offerings, but they all fell woefully short of meeting leader expectations. Simply stated, these solutions did not have the capabilities to effectively address the defined problems.
But when the leadership team saw the EFFY demo of RAID Healthcare, including the reconciliation and analytical tools that could gather and compare data enterprise-wide, detect deviations, issue alerts and offer an integrated workflow to guide the 'fix,' they were overwhelmed.
"This is phenomenal, but can it really perform and do all that it promises to do?" they asked.
The answer was "yes."
Furthermore, there was no need to discard the existing system since EFFY RAID Healthcare would overlay the current installation and provide the needed analytics and drive the corrective actions needed.
Best news of all -- especially to the CFO -- was that EFFY RAID Healthcare eliminated the need for large up-front acquisition costs, representing a financial transaction that would fall within budget.
"We really liked the fact that RAID was proven technology outside of healthcare," expressed the leadership team. "The fact that complicated industries worldwide, such as telecom, rely upon its actionable analytics gave us an extreme level of comfort."
RAID Healthcare proved to be a solution that over-delivered.
Leaders initially identified seven rules that governed authorizations for infusion treatments, and tasked the RAID Healthcare tools to begin monitoring CPT charges. The resulting RAID Healthcare-generated alarms were so critical to diagnosing the problems with the authorization process and the opportunity was so great to initiate corrective action, the hospital leaders quickly expanded the rule set to 10.
Results and ROI
EFFY RAID Healthcare and its powerful analytic tools have now been utilized for six months.
Savings related to denials and write-offs continue to accrue and are upwards of $800K in the first six months of operation in this clinical area.
Back end processes are streamlined, relieving stress and time constraints imposed on the clinical staff.
Inadequate or missing documentation of medical necessity has been addressed, allowing the hospital to transition charges to patient self-pay or to initiating a change in the course of treatment.
Testimonials to EFFY and RAID Healthcare
"With RAID Healthcare, the opportunity for better claim reimbursement is evident.
It's always a challenge with Medicare, but given the complexity of commercial claims and the daunting challenges, we are really delighted to now have these processes under control."
"We love RAID Healthcare. It's really groundbreaking. And the EFFY implementation and support teams go above and beyond expectations every day. They are totally flexible, and truly empower us to achieve financial and clinical goals as well as manage IT within our own department."