Our RCM Team Transforms Predicament To Payment For A Cardiology Client

CASE STUDIES

Leaving collections on the table is the last thing any provider would want to do. Our client was struggling with their collections and explained to us their concerns.

BUSINESS NEED

My cardiology services thrived and I relished offering patient care competently. The problem arose when I could not see the results in the practice bank account. I ensure that my front desk staff had called the payer numerous times. The answer became obvious to us, either we had to wait for a few more days, or we had to raise a request for review. We were told a few claims were “not on file”. Left with no choice, we continued the process. It became a vicious circle. Honestly, it isn’t a cool picture for any provider to see the collections left on the table, and I could see they focus shifting to the billing and collections from patient care. While on one hand I could see patients flowing in, the subsequent collections were not being reflected.

As a physician I trust in devoting myself to patient care, and the payment that never got posted only added to the woes. Another quandary was that we saw most of the issues arising from the same Medicare HMO payer. This obviously meant that the collections of the upcoming months too, would meet the same end.

I could think of no other measures except outsourcing my billing to a medical billing service.

SOLUTION

Roldem Healthcare Services came into the picture. I was hopeful that I would soon see results, but never this fast. They proved to be efficient and competent. Their representatives would call and find the status of payments along with remedies for getting payments made.

HOW DID Roldem Healthcare Services HELP WITH ROOT CAUSE ANALYSIS?

The Roldem Healthcare Services
team reached out to one of our major Medicare HMO payers with an outstanding A/R that had a monthly collection target of 4 million. Our payer suggested that claims were paid and adjudicated, but we were not getting any remits to post, all we had received was assurance that the case is being reviewed and that we needed to wait 10 days to get the EOB’s. The claims specialist requested to speak to a Tier 2 representative of the payer, the case was reviewed in detail and the payer software was experiencing a technical glitch in their system which caused this trouble. The representative assured us that they would expedite the issue as a special case and suggested we wait for 20 days. By the end of the 20 days we had received all of the EOB’s and the payments were finally posted in the system. The total collection was 5.25 million, we had surpassed our target by 1.25 million.

PROACTIVE SOLUTIONS FROM

Another payer with outstanding A/R had most of the claims noted as “not on file” and the payer had a restriction of 10 status calls per day.

The Roldem Healthcare Services team worded on these claims to determine the reasoning for the “not on file” response. The team determined that the payer had updated their processing system and there was a gap in the integration of the old and new systems at the payer end.

Resolution was planned with the payer to send a compiled spreadsheet of the claims affected. The spreadsheet had approximately 600 to 700 encounters, with billed charges at approximately 1.5 million. The follow up from the Roldem Healthcare Services
Global team with the payers ensured that all monies were collected within a month. Thanks to the proactive measures taken by the Roldem Healthcare Services team we exceeded our targets every month that followed.

CONCLUSION

In conclusion, I am completely satisfied with the services of this medical billing service. I am able to focus on patient care, rather than the monotonous billing paperwork and processes.