Optimizing Revenue and Reimbursement Cycles for a Leading Multi-Hospital Healthcare System

This client is one of the largest non-profit healthcare organizations in the US, operating 5 hospitals and more than 80 outpatient facilities. The organization struggled with fragmented systems, inconsistent processes, and a high volume of claims across multiple insurance providers, resulting in rising operational costs, revenue loss, and compliance challenges. Managing these issues internally jeopardized its ability to maintain high-quality patient care.

The client sought Adobe Data’s assistance in optimizing their healthcare reimbursement cycle by:

• Developing a best-practice framework for revenue cycle processes across all of the client’s facilities
• Streamlining key steps in the healthcare revenue cycle, including pre-authorization, patient eligibility verification, medical coding and charge capture, and insurance claims processing
• Establishing a comprehensive denial management protocol to enable prompt resolution of denied claims across multiple payers
• Enhancing cash flow through improved revenue cycle management (RCM)

During an audit of the client’s hospitals and outpatient facilities, our team identified variations, revenue cycle bottlenecks, and areas of inefficiency. To uncover gaps, we also assessed the client’s existing technology infrastructure, including electronic health record (EHR) systems, coding tools, and claims management solutions. Here’s what we found:

• Some hospitals took up to 14 days on average to submit claims
• Denial rates varied between 10% and 45% across facilities
• The organization processed an average of 2,500 claims per week, with 38% backlogged, leading to delays in reimbursement
• Coding errors were found in 15% of submitted claims
• The average denial resolution time ranged from 21 to 35 days across facilities
• Only 60% of facilities were integrated into the central EHR system
• The organization faced an estimated $2 million in annual revenue loss due to missed charges, under-coded services, and unbilled procedures
• Inefficiencies in the RCM process resulted in an additional $2 million in annual operational costs

Given these challenges, we devised the following plan of action:

• Consolidate the various EHR systems across all hospitals and outpatient facilities
• Implement a unified protocol for claim submissions across all facilities to minimize time variations
• Enforce standardized medical coding and billing practices
• Address and resolve denied claims from multiple payers to reduce the backlog
• Clear the current backlog of claims and establish process improvements to prevent future backlogs
• Manage related healthcare back-office operations