Addressing authorizations Specific issues regarding treatment authorizations were particularly challenging, impacting the organization's ability to mitigate claim denials for treatments provided in the outpatient infusion therapy center. These occurred primarily when there was a deviation in the plan of care, burdening clinical and operational teams to secure authorizations for treatment necessitated by a change in the patient's health status. These approvals were not processed with the payer for a variety of reasons.
Too often, the claims were denied, even though the care was rendered, leading to a write-off for the hospital system. While the overall operating system (OS) registered the charges, it failed to confirm reauthorization. The hospital also had trouble documenting medical necessity in order to ensure reimbursement. Again, the OS was burdened with claim denials stemming from documentation failure.
Seeking the right, cost-effective solution Revenue cycle leaders at the not-for-profit hospital evaluated several vendor solutions. Because the hospital had already invested substantial funds in its existing OS and analytic tools, they did not want to discard or replace the OS with an equally expensive transaction-based model. After reviewing various product offerings, the hospital found that every option failed to have the capabilities they needed to effectively address its issues.
Finally, they chose an actionable “real-time” or near real-time data analytics platform that was powered by an RCM optimization tool. Used worldwide by leading health care systems, telecom companies, utilities, retail and other complex industries, this RCM optimization tool can audit and trigger efficiency actions in a way that is non-intrusive. What’s more, the solution’s efficiency platform overlays existing systems to help health care organizations compare massive amounts of data across their total enterprise, detect exceptions and problems, and guide actions and interventions to improve efficiency.
The health care organization saw that the actionable RCM solution had the reconciliation and analytical tools that would help them to gather and compare data enterprise-wide, detect deviations, issue alerts and offer an integrated workflow to guide the 'fixes' they would need.
Even better, they did not have to discard their OS because the RCM solution would overlay the current installation, provide the needed analytics and drive the corrective actions needed. The new RCM solution eliminated the need for large upfront acquisition costs, representing a financial transaction that would fall within their tight budget.
