Overview:

This case study unravels the intricate challenges faced by a healthcare organization, encompassing overcoding, credentialing issues, unpaid codes, unprocessed copays, and inconsistencies in patient statements.

The Problem:

The organization grappled with overcoding, credentialing challenges, unpaid codes, unprocessed copays, and inconsistencies in patient statements.

The Solution:

1. Implemented a streamlined coding process to address overcoding issues.
2. Revamped credentialing procedures for enhanced accuracy.
3. Implemented a robust system to ensure all codes are processed, and copay discrepancies are promptly addressed.
4. Introduced a systematic approach to rectify inconsistencies in patient statements.

The Results:

1. Successfully resolved payment issues related to CPT codes 99254 and 99255 with Medicare for initial visits.
2. Achieved a notable 40-50% reduction in rejection rates.
3. Corrected ICD codes during a comprehensive Medicare audit, ensuring compliance and accuracy.
4. Marked increase in average monthly profit by $15,000.
5. Calculated RCM cycle error rate at an impressive 5.97%.

Conclusion:

This case study illuminates the successful execution of multifaceted solutions, addressing overcoding, credentialing challenges, unpaid codes, copay discrepancies, and inconsistencies. The tangible results underscore the organization’s commitment to optimizing revenue cycle management, showcasing improved financial outcomes and operational efficiency.