Client Profile:
A multi-location healthcare system comprising of 11 hospitals and more than 250 providers.
Challenge:
A multi-location healthcare system comprising of 11 hospitals and more than 250 providers was seeing a steady increase claim edits, along with denials, coding errors and charging errors. The client’s goal was to mitigate growing risks and ensure clean claim submission. Implementing a prebill edit review helped to eliminate time and labor costs for denied claims, re-submittals, and a timely appeal process.
Still feeling the financial impact of the pandemic, such as increased costs and lower operating margins, the client had to spearhead issues quickly and find efficiencies to ensure revenue integrity and financial sustainability.
Approach:
AQuity addressed the project with the proven method of a Pre-bill edit review function, a proactive approach that preemptively corrects potential claim edits to help healthcare providers proactively prevent denials. After an initial assessment to establish a threshold for the engagement, our team of credentialed specialists review coding, charging or billing edits proving remediation and clean claim submission.
A critical element of a Pre-bill Edit requires a successful balance of coding guideline application, coding, charging, and billing accuracy. AQuity worked with key individuals to determine the greatest areas of risk, payment, and documentation challenges. To identify the root cause of issues, AQuity conducted complete claim examinations instead of simply assessing codes assigned, as typically done in a standard coding audit. We incorporated training and vetting processes to customize the solution to better suit the clients’ requirements, aligning with the organizations existing workflows.
The initial analysis addressed the immediate concerns to stop repetitive costs by eliminating problematic trends, with subsequent steps addressing the long-term impact, focusing on education and documentation complexities to enable the hospital system to train accordingly. AQuity’s goal was to move from transactional to transformative change across the healthcare continuum.
Results:
Had AQuity not stepped in, the inaccuracies would have been submitted, and a significant financial impact incurred. In the one-year time frame of the engagement, AQuity addressed 33,570 claims with prebill edits and recognized $341,653,095 of charges recouped due to edit remediation. Organizations that invest in this approach ensure documentation supports coding compliance Ultimately, a prebill function promotes revenue recovery before claims submission, minimizing expenses of denied claims that ultimately can impact cash flow.
Pre-bill edits provide real-time feedback to prevent revenue leakage and denials while educating coders or billers for improved accuracy, helping healthcare providers proactively prevent coding edits or denials. It sounds simple in theory; however, many providers struggle with implementing this mid-cycle process. The result is improved turnaround times and, most importantly, a reduction in claim edits, denials, or write-offs.
To learn more about AQuity Solutions Revenue Integrity, contact us today at info@aquitysolutions.com.
