Healthcare Payer Support

Unresolved Claims - Our partners encountered challenges with unresolved claims in accounts receivable (AR) exceeding 90 days, comprising approximately $ 4.34 Million in unresolved claims that proved difficult to effectively manage the operations with their internal team.

In two months, we reduced greater than 90 days bucket in AR from $ 4.34 to $ 3.25 million using effective communication tools, payer portals , and CRCS-certified AR collectors, enhancing efficiency and revenue cycle management.

Underpaid Claims - Receiving payments lesser than the contract rates from payers

In our preliminary review of settled claims, AMI identified over 1,700 inaccurately compensated claims, totalling more than $204,000. We coordinated with the provider relations team on the payer's end and, through ongoing communications, were able to fully recover all underpaid claims.

Net Collection Rate (NCR), First Pass Ratio (FPR), and Clean Claims Rate (CCR). - Their NCR, FPR, CCR was less than 95% due to inefficiency in implementation of collection process and challenges in claims with huge outstanding balances.

We've maintained a steady 95% Net Collection Rate (NCR), First Pass Ratio (FPR) , and Clean Claims Rate (CCR). This was achieved by effectively working on timely follow ups, Maintaining a rigour and working on rejections and denials establishing a communication grid between AR and other departments to ensure timely updates from AR being followed by the other departments.

Sending Patient Statements And Collecting Balances - Incorrect management in sending patient statements and subsequent balance collection

From $700,000 to now less than $350,000 in patient collections within a span of 2 months, the team adhered to structured follow up methods based on the Fair Debts Collection Practices Act (FDCPA)

The Resolution Rate - The Resolution Rate of AR Collectors fell below 80%

We helped them increase their Resolution Rate from less than 80% to now at 97% as we hired the associates with the necessary CRCS certification by AAHAM. The associates followed the updated SOP rigorously with seamless communication with the insurance counterparts.

Referral and Authorization - With over 50% of rejection ratio in the authorization and re-authorization of services. Resulting in burdening the patients.

Currently with the robust protocols and process improvements in place the rejection ratio has dropped from 50% to 10%. This was made possible by 100% live audits, which then was followed by real-time feedback and frequent training workshops for the associates.

Quality Management System - The clients were lacking the Quality Audits aspect from their day to day operations.

Currently with 99% accuracy, the quality of operations have reached to a better optimized stage. We have adopted the DPO methodology for non-fatal defects and DPU for fatal errors.

Denial Rate - The client faced a denial rate of over 43%

By implementing 3 step disposition method to pin point the denial and its root cause which eventually helped in reduction of denials from 43% to 10% in 2 months which is currently at 4%

Claim Rejections and Denials - The facility continues to face challenges with a staggering high rate of 32% claim denials and rejections, resulting in significant revenue loss. Pinpointing and addressing the root causes of these denials remains an obstacle, necessitating a deeper investigation into their billing processes.

Rejections present a significant threat to medical practices' financial health, leading to substantial revenue loss. Our analysis led to actions that improved the rate at which claims were accepted on the first attempt. Through initiatives like improved coding accuracy and staff education on payer policies, we streamlined rejections, reducing the rate from 32% to 15% within the first 3 months of our partnership. Additionally,without denial management processes, providers may face a 10% to 15% revenue decrease. We conducted data analysis to identify denial patterns and root causes, optimizing processes. Our CRCS- certified associatescollaborated closely with facility revenue cycle teams to streamline denial management processes, ensuring expertise in revenue cycle management. This led to a noteworthy improvement in cash flow, increasing monthly collections from $3 M to $4.2 Mwithin the first few months of our partnership.

Outdated Billing Software - Their reliance on outdated billing software has led to inefficiencies, hindering their operations. The lack of automation worsens this issue, resulting in frequent manual errors in codingg and billing processes reducing their First Pass Ratio to 70%. While not purely a software issue, the interface and design of billing software can contribute to human error during data entry.

Implementation of Advanced Billing Software - With nearly two decades of experience, our team at AMI has collaborated with numerous firms across a variety of platforms. During our initial consultation with a client, proactive coordination among intra-vertical teams, including coding, charge entry, and eligibility verification, we established a comprehensive approach from the outset which led to a significant improvement in theFirst Pass ratio from 70% to 90%.

Ineffective Communication - Inadequate communication between billing and clinical teams leads to incomplete or inaccurate billing data. Furthermore, the absence of a streamlined procedure for capturing and documenting chargeablee services intensifies this issue which resulted in less than 35 claims being processed in a day.

Training and Collaboration - Training sessions were conducted for billing, and AR teams to improve communication and ensure precise documentation of chargeable services. The team was regularly informed about the ongoing updates in ICD code regulations to facilitate the process. A collaborative approach was adopted to bridge the gap between the intra-vertical teams of the partner with AMI along with the partner’s on-shore team. Partners team at AMI Team had a detailed analysis of the inventory and they executed the workflow implementation plan while leveraging various automation tools to optimize and prioritize the claims. This strategic approacheliminated redundant tasks like manual data entry, duplicate data verification, repetitive claim status checks, manual appointment scheduling, and redundant documentation review, enhancing efficiency and enabling manpower reallocation to other essential functions, effectively leveraging technology. These initiatives resulted in a notable increase in staff productivity, rising from 35 to 60 claims per day.

High Cost - Inadequate training at outsourcing firms leads to costly errors for providers. Errors such as inaccurate coding, billing discrepancies, and compliance breaches have resulted in significantt losses of both money and time. Correcting these mistakes by redoing the process in its entirety requires additional resources and investments in training and process improvements.

AMI consistently emphasizes thorough and extensive training programs, which includes simulation-based training on charts to better equip employees for their day- to-day tasks once they are integrated into real-life account management. This initiative has led to fewer errors and lower associated costs for the billing company. This approach aims to facilitate a smoother transition and minimize the learning curve, ensuring that employees can adapt to the actual processes seamlessly.

Additionally, establishing clear communication channels between AMI and the billing company helped streamline the process and ensure the calibration with expectations which further helped in optimizing operational efficiency. This strategic move alone helped our partner save. $2 Million in revenue over the span of our partnership.

Access To Quality - According to eClinicalWorks recent market research, coding mistakes account for a staggering 63% of medical billing errors. Incorrect coding in Revenue Cycle Management can lead to lower accuracy in claims submitted for billing, resulting in higher rejection and denial rates, decreased clean claim rates, and reduced coding accuracy scores, ultimately impacting the overall quality of revenue cycle management and requiring additional resources for error correction and staff training. At the beginning of the partnership between AMI and the billing company, the quality audit scores stood at approximately 85%.

AMI carried out rigorous adherence to partner rules and quality measures, coupled with transparent communication, to bolster accuracy, compliance,, and financial performance, we proudly call this Co-managed Operations. Prioritizing compliance with industry regulations to ensure alignment with legal standards and enhance overall operational integrity while achieving a 99% compliance rate within a span of 6 months.

Talent Acquisition - Their initial outsourcing partner lacked the necessary talent and certifications to handle the tasks assigned to them. Coders with certifications in CPC, CCA, CRCP, etc. will help them not only validate skills and knowledge but also demonstrate a commitment to maintaining high standards of professionalism and compliance within the healthcare revenue cycle and coding domains.

The billing company opted for AMIbecause of our proven track record of possessing the required talent and certifications to effectively handle assigned tasks. We prioritized thorough vetting processes to ensure harmony between partner capabilities and the demands of the tasks, thereby minimizing risks and optimizing performance. Our employees are already CPC, CRCP and CCA certified, significantly reducing partner training time. Additionally, we annually renew these certificates as per regulations, covering the expenses ourselves.

AMI's strategic location and partnerships in Pune, India attracts top talent, fostering a diverse and adaptable workforce. With nearly two decades of industry experience and domain expertise, our brand embodies credibility earned through years of ethical practices. We offer competitive pay structures and comprehensive employee benefits to support growth and satisfaction. Our inclusive work culture ensures a harmonious environment for all team members.

Scalability : In addition to their lack of made-to-measure operations not being customized to client needs and inability to scale team size appropriately, the company faced challenges with ramping up and down. Longer notice periods and durations were required to scale up with certified and trained resources, posing further limitations on their ability to meet client demands efficiently.

To overcome scalability issues and ensure customer satisfaction, AMI provides tailor-made solutions for our partner’s unique needs while maintaining the ability to efficiently scale team size swiftly. AMI has trained professionals on standby in their bench resource pool for partner scaling needs. We offer flexible ramp-up and down options, along with minimum notice periods and durations, ensuring scalability with certified and trained resources to meet partner needs effectively.

Speed of Communication - The company encountered issues with communication efficiency, including delayed responses to emails, failure to acknowledge process updates and delayed delivery of operational reports. Additionally, there was a lack of forecasting regarding staffing availability which resulted in poor and improper allocation of volumes.

AMI ensures seamless partner processes through clear communication channels, providing daily reports and attendance sheets for efficient task allocation. We prioritize acknowledging process updates promptly and excel in forecasting associate availability. Our proficiency in co-managed operations enables rapid execution and near-instantaneous responses, with ask reports shared within hours if not minutes, demonstrating our dedication to speed and effectiveness giving an overview to our partners for better agility with strategic planning.