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Case Studies
Orthopedic Group in Nevada
Overview
- Privately held Orthopedic group in Nevada
- Specialty: Orthopedic (Joint Replacement, Spine Care, Pain Management, Physical Therapy, Open MRI, Trauma Fracture Care, Upper Extremity Surgery, Sports Medicine, Etc.)
- Over 50 years of history of providing the highest quality orthopedic services for patients throughout Nevada
- Clients’ Revenue per year > $20M (2020)
Implementation
- Daily claims submission
- Quarterly coding audits and constant auditing of coding by in-house CPC coders
- Weekly discussions with front staff to review Prior Authorization Denials
- Improved payment turnaround time through proper eligibility checks and escalation of un-insured patients prior to the appointment date
- Fix denials within 48 hours
- Follow up date based collection follow ups and daily follow on denials
- Aggressive follow up on claims passed 150 days from Date of Service
- Real-time Analytics reports (DOCTRIX®)
- Weekly progress reports
- Monthly Revenue analysis report
- Quarterly Onsite Strategy Discussions
- Quarterly Discussions with Providers
- Best Practices recommendations
Challenges
- An average of a 12-day delay in surgery claim submission
- Non-specific coding and lack of documentation (Non-compliant coding related to E & M, Bundling issues)
- Not Securing Prior Authorization for required services resulting in loss of revenue
- Increased eligibility related denials
- Increased denials related to Physical Therapy Cases
- Lower first time payment rate
- Higher zero pay CPT%
- Poor transparency to overall and individual performance of providers
Results
- Billing turnaround time improved from 7 to 4 days
- Seamless transition to new improved Practice Management System helping with the coding and documentation challenges
- Reduction in the 90+ Insurance AR from 40% to 15%
- Reduction in the Days in AR from 49 Days to 25 Days
- Clean Claim rates improved to 99%
- Consistently maintained Zero pay claims at less than 2%
- Resolved claim % at 90 and 120 days is 99%
- 100% transparency into RCM processes
- Best in class & compliant business processes
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