Use Cases

Real Challenges, Real Solutions

As a healthcare provider, you're likely focused on delivering quality patient care, but the reality is that your practice's financial health is often tied to your billing vendor's performance. The billing and revenue cycle management process is complex, and even small mistakes or inefficiencies can have a huge impact on your revenue. Many providers unknowingly lose money because they don't have full visibility into the work done by their current RCM vendor.

Here are some real-world use cases where Advanta-Wise’s RCM audit services uncovered hidden issues, helping providers optimize their revenue cycles, reduce denials, and recover lost revenue.

1. Missed Revenue Due to under billing: A Hospital's Hidden Loss

Problem

A multi-specialty hospital partnered with an RCM company to manage their billing and collections. Over time, the hospital noticed a decline in revenue, but without a clear explanation as to why. They assumed it was a matter of fewer patients, but after our RCM audit, we discovered that the hospital had been consistently under coding their procedures—especially for high-complexity services. This was due to the RCM vendor not correctly documenting or coding certain services, leaving money on the table.

Solution

After identifying this issue, we helped the hospital implement better coding practices. We also educated their staff on proper documentation, ensuring that they captured the full value of every service provided. As a result, the hospital began to see an increase in reimbursements.

Impact

The hospital recovered over $200,000 in lost revenue in the first 6 months after the audit. More importantly, they now have a system in place to ensure that they are correctly coding every claim.

2. Chronic Denials and Delays: A Physician's Practice Struggling with Cash Flow

Problem

A private physician’s practice faced persistent issues with denied claims and slow payments, impacting their cash flow and ability to reinvest in the practice. Despite using an established RCM company, their denials were frequent, and they couldn’t identify the root causes. They were caught in a cycle of resubmitting claims without understanding the issues at hand.

Solution

We conducted a comprehensive AR audit to analyze the denied claims and discovered that a significant portion of denials stemmed from incorrect insurance verification, missing patient information, and coding errors. We implemented a more thorough insurance verification process and trained the practice’s front office staff to catch these issues before claims were submitted.

Impact

Within just 3 months, the practice’s denial rate dropped by 35%, and outstanding AR dropped by 20%. The practice began receiving payments faster and regained control of their financial stability.

3. Inefficient Payment Posting: A Medical Group with Disorganized Financial Records

Problem

A medical group with multiple specialties was struggling with payment posting issues. Payments were often recorded incorrectly, leading to discrepancies between what they received and what was reported. This created confusion and resulted in financial mismanagement, affecting the group’s overall profitability.

Solution

We conducted a thorough payment posting audit to identify where the errors were occurring. After pinpointing the issue, we streamlined their payment posting process and implemented a system that ensured every payment was accurately reconciled with remittance advice. We also automated part of the process, reducing human error.

Impact

The medical group improved payment posting accuracy by 98% and drastically reduced the time spent on reconciling payments. As a result, the practice's financial records became more transparent, and cash flow stabilized.

4. Hidden Billing Errors: A Specialist’s Practice with Unnoticed Mistakes

Problem

A specialist’s practice noticed a decline in their overall revenue but couldn’t figure out the cause. After our initial audit, we discovered several billing errors that had been overlooked for months. These included incorrect coding for procedures, failure to submit charges for services rendered, and missed opportunities for in coding.

Solution

We worked with the practice to correct all the billing errors, ensuring that every service rendered was properly documented and coded. We also implemented an ongoing audit process to catch these issues early and prevent future mistakes.

Impact

The practice recovered $150,000 in lost revenue due to the billing mistakes and significantly improved its overall revenue cycle management. Additionally, they have since adopted regular internal audits, ensuring continued financial health.

5. Low Reimbursement Rates: A Dental Practice with Unfair Payer Practices

Problem

A dental practice was facing low reimbursement rates from insurance companies, but they didn’t understand why. They had been working with the same RCM Company for years, but their reimbursement rates seemed to be lower than industry standards. After our audit, we discovered that the RCM Company had not been following up with payers on underpaid claims, resulting in significant revenue losses.

Solution

We reviewed the practice’s payer contracts and helped them renegotiate certain terms to ensure fairer reimbursement rates. We also recommended a more proactive approach to following up on underpaid claims, ensuring that every claim was resubmitted or appealed when necessary.

Impact

The practice increased their reimbursement rates by 18% in the first quarter following our audit. They also recovered $80,000 in underpaid claims from the previous year.

6. Complex AR Aging: A Hospital Group Struggling with Unpaid Claims

Problem

A large hospital group had an aging AR problem, with over 60% of claims unpaid after 90 days. Their existing RCM vendor had failed to follow up effectively on aging claims, and the group was unsure how to recover these funds.

Solution

Our team performed an in-depth analysis of the AR aging reports and worked with the hospital’s internal billing team to prioritize follow-ups based on claim value and age. We implemented a streamlined follow-up process that ensured claims were addressed promptly and that any issues with payers were resolved quickly.

Impact

The hospital group reduced their AR aging by 45% within 6 months, and their collections rate improved by 25%. They now have a robust follow-up process in place, ensuring faster payments and reduced aging.