Success Story Healthcare

Emergency Department Improves Claim Coding to Increase Revenues

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The deployment AI-based tool for predicting the erroneously coded chart

The client operates ER (Emergency Department) across the US. The revenue per year is $22M with an average of 18,000 visits per month. They have a collective total of 45 billing/collections staff, both onshore and offshore.

The client incurred revenue loss due to inaccurate charging and coding processes for (ED) patients. The inconsistencies and reduced quality of the processes not only hindered the performance but also lead to denial of claims. The deployment AI-based tool for predicting the erroneously coded chart and generating audit samples led to improvement in accuracy, consistency in coding, and error prediction. It also enhanced revenue, while also lowering costs, reducing the number of failed claims, and improving coding accuracy.

the Results

Key Outcomes

Apexon helped the client on enhancing several performance metrics and opportunities for revenue improvement by streamlining of coding technology and services for the client. They have since gone on to realize these stated benefits and much more as state below:

Allocated 40-50%
staff redeployment

60% quality
improvement

Zero IT maintenance
& audit bias

The days in AR was
maintained with 40 days

There was a $12 increase in the
overall revenue per visit billed
compared to previous years

Overall 90+
AR was at 10%

The challenge

7 key areas

Filing Denials Timely filing denials due to delay in receiving documentation and missing charges

Denials & Information Issues High rate of eligibility related denials and incomplete demographic information

Coding & Quality Issues Inconsistency in coding performance and drop in quality

Underpayment Tracking The non-tracking of several underpayment issues

Denied Claims Denied claim due to charge and coding issues

Reduced Acuity & Revenue Reduced acuity and revenue per encounter

Compliance Risks Unidentified compliance risks

The Solution

5 key areas

Based on the assessment, the Apexon team recommended the following technology initiatives to transform the reconciliation and quality procedures:

Improve Coding

Usage of technology such as assisted coding and error prediction tool to improve accuracy and consistency in coding

Training for Coding Denials

Trained the team on coding standards and implementing process guidelines to handle regular coding denials

High-level Reporting Solution

Implementing high-level reporting solution to identify and address anomalies

Eligibility Verification

100% eligibility verification before submitting a claim to the payer

Improved Process Efficiency

Change in the workflow to improve the overall process efficiency

A strategic approach towards quality led to the creation of an AI-based automation tool. This resulted in accurate and timely predicting of the erroneously coded chart and generating audit samples which were crucial in improving the performance and revenue. It delivered the following:

It helped maintain manually-coded and auto-coded sheets based on daily coded data and corresponding audits

Performed as an error prediction tool with customizable algorithm for predicting error codes and the likely reason for the inaccuracy

It helped in prioritizing error charts with maximum error propensity across different critical to quality fields

It helped in generating reports and monitoring quality with an eye on improving the coding process

Success Story Healthcare Emergency Department Improves Claim Coding to Increase Revenues