Healthcare RCM Case Studies
Revenue Cycle Management (RCM) is the process of determining, tracking, and collecting revenue from patients. It begins at the initial encounter (appointment) and continues until the resolution of outstanding balances. The RCM process also includes coding activities and administrative functions such as the billing process.
There is an inherent need in today’s RCM -- streamlining inefficient processes, many which are paper-based, into completely electronified documents which eliminate the need for manual review, data entry, and manual posting! Although digitization and electronification continues to grow across the revenue cycle, many paper and PDF documents still remain requiring manual review, data entry, and posting. EOBs/EOPs and correspondence letters are two such documents.
The following Unique Case Studies of Platform Modernization provides an overview on how OrboGraph solutions are deployed across a wide range of RCM payment aggregators, banks providing medical lockbox services, and clearinghouses.
Technology Translates into Business Value
All modules of OrboAccess reside on OrboGraph’s Healthcare Payment Automation Center (HPAC). A cloud- based infrastructure, the HPAC platform enables connectivity with any revenue cycle corporation.
Through electronification, revenue cycle servicers reduce costs while providing their healthcare provider clients with the solutions that improve AR collections, reduce receivables, improve quality of posting and support better access to patient data upon demand to resolve billing issues. Additionally, both administrative and clinical data is available to feed downstream business intelligence (BI) and data analytics systems for more detailed financial analysis of trends. By upgrading from legacy systems with heavy human intervention and outdated processes, RCM companies modernize their existing platform.
Case Study: Large US Bank - Medical Lockbox
Client Profile #1: Large US Bank Offering Enhanced Medical Lockbox Services
Delivering Value Through AI-based Payments Electronification
At an industry level, healthcare providers have not achieved near 100% EDI 835 adoption, leaving a large volume of EOB remittances and checks in the payment stream. To address this market need, the client initiated a workflow redesign to automate healthcare payments and remittances for an integrated receivables experience, also enabling data interoperability.
The bank was building a single healthcare portal platform which would enable their clients to have a single view into their medical receivables.
The bank’s healthcare payments sales team, while treasury product knowledgeable, lacked critical expertise in nuances of the payment posting process. The product and operations teams were supported with best practices for onboarding large healthcare system clients for EOB conversion.
Case Study: RCM Companies
Client Profile #1: A Cloud-Based EHR & RCM Service Provider
This organization had struggled with their existing offshore BPO vendor. This vendor provided paper EOB conversion to 835 management for over 10 years via the use of an extensive data entry network of keyers. The RCM Cloud Servicer realized a need to automate and address operational gaps including: process visibility, cost, reliability, process controls, and posting errors — an ongoing problem for healthcare providers and their patients.
After extracting all data from the EOB via AI technology, customization logic was created to translate metadata into customized EDI 835 formats for individual practice management systems for select healthcare providers. As part of this process, Access EOB converts proprietary adjustment codes read from the EOBs/EOPs into specific ANSI adjustment codes.
During initial quality benchmarking, OrboGraph committed to major quality improvements. We anticipate postability to be 99% — significantly higher than the BPO vendor. The RCM company will also see significant benefits to their downstream workflows and analytics.
Client Profile #2: A US-based Healthcare Payments BPO
This BPO company needed an automated infrastructure tool within their daily business processes that could lift data from EOB images. They had struggled to build a platform with internal technology. As a result, they were managing a large, offshore workforce with very manual and laborious controls finding it tough to maintain consistent output quality. Additionally, international labor rates were increasing, which drove up internal costs and reduced already slim margins — coupled with a competitive labor pool that was becoming more difficult to scale. The decision to build vs. buy came to the forefront after two years of analysis.
The company connected to OrboAccess and HPAC in a hybrid deployment, leveraging the OrbNet AI technology as an automation platform to automate manual processes and leverage the business intelligence capabilities of the system. Additionally, individual operator metrics were now trackable and better managed by the operations team.
OrboAccess implementation was highly successful. The flexibility of the OrboGraph platform has allowed this company to not only address their own automation issues, but also to scale operations for multiple new clients. They have established a strategic partnership with OrboGraph and are looking for other ways to collaborate.
Client Profile #3: A Traditional RCM Outsourcer
This organization struggled with internal EOB data entry processes that strained their U.S.-based labor force. Complex and customized client requirements had to be managed side by side with handling large amounts of paper EOBs. Correspondence letters were lost in the shuffle and often ignored.
EOB processing is no longer being done manually. The RCM Outsources leverages Orbo-Access for technology-based auto-posting, avoids duplicate posting of 835s and EOBs and has revamped internal data entry workflows for correspondence letters. Results: Refreshed Archive and Search.
Today, they’ve connected their once paper-based processes to their electronic denials system and are highly satisfied with their new archiving and search capabilities. They use OrboGraph 835s to feed into denial tools., providing a full scope of payments and trends.
Case Study: Clearinghouses
Client Profile #1: Industry-Leading Clearinghouse -- a Subsidiary of a US-Based Fortune 500 BPO Service Provider
This clearinghouse began their OrboGraph partnership because of their struggles with paper remit rates that reached 30%+. With their contract compliance solution relying on ERAs (835 EDI files), a prevalent gap was apparent as they were missing 30% of providers’ remitted claims.
By collaborating with OrboGraph, this clearinghouse developed a solution to close the claim gap by converting paper EOBs to ERA and integrating the results holistically into their contract analysis product -- with the end goal of direct lift on recovered revenue and improved downstream BI. This clearinghouse leveraged OrboGraph’s OrboAccess technology to deliver high-quality EOB conversion, patient payments conversion, and correspondence indexing (extracting key fields from non-ANSI correspondence letters that are indexed and categorized by type of letter), and hosts the data on their rebranded OrboGraph Healthcare Payment Automation Center (HPAC) Portal.
The results were improved downstream business and denial intelligence from the automated payment posting functionality. Their providers receive 100% of their contract analysis and audit processes, along with a direct lift on both identified and recovered revenue from more electronic remits being fed into the audit process. This has led to a shortened audit process, as they now possess a more complete claim population represented in the system, yielding a holistic view into their underpayment landscape. Furthermore, by reducing the chances of underpayment, they provide direct benefit to providers through increased accuracy in patient billing and communications.
From the marketing & sales perspective, their partnership with OrboGraph has allowed them to mature from a production-oriented approach -- focused on direct mail and email to drive activity through the pre-sale -- to an OrboGraph-supported demonstration process. They now take an increasingly strategic approach through individual partnerships with other PMS companies and RCM companies while leveraging bundled products, which are the engine behind the bulk of the business driven through their partner program.
Client Profile #2: Healthcare Solutions Provider with Clinical Data Clearinghouse
Like many other businesses in the world, this clearinghouse -- specifically their RCM processes and functions -- was greatly affected by the COVID-19 pandemic. With the shutdown of offices not just in the US but across the world, the clearinghouse experienced issues and delays with its current vendor -- which was unable to perform tasks from a work-from-home environment due to HIPAA. To ensure business continuity, HIPAA compliance, and build processes that are pandemic-resistant, this clearinghouse embarked on the initiative to transition from its current offshore business process operation (BPO) vendor to a technology vendor. The clearinghouse understood that in order to ensure business continuity with minimum delays, it must leverage AI technologies.
OrboGraph’s AI technology minimizes the need for manual intervention in the processing and electronification of paper-based remittances and EOBs/EOPs, allowing the clearinghouse to continue processing with minimum interruptions or delays -- even during the COVID-19 pandemic. In addition to its technology, OrboGraph deploys a globally-distributed network of vendors for quality assurance to ensure quality, enabling the clearinghouse to reach 99+% accuracy levels for their data.
Additionally, the clearinghouse is leveraging the advanced correspondence indexing solution, including self-service categorization, to increase its offerings and value to its clients. The data is also being utilized by downstream BI solutions.
By transitioning to AI technology, the clearinghouse has the capability to ensure that its processing of paper-remits and EOBs/EOPs is resistant to pandemics like COVID-19 and other natural disasters. They are also benefiting from the increase in data quality from both remits and correspondence letters to grow the value of its business intelligence and analytics.
Additionally, the AI technology has reduced the amount of time for onboarding and has the ability to scale with the business as the clearinghouse looks to increase its market share.
Client Profile #3: A Traditional RCM Clearinghouse
Most of their hospitals are working with a bank lockbox, which involves processing and posting large volumes of scanned copies of checks/EOBs. For multi-faceted hospitals and systems dealing with large volumes, decentralized business processes, multiple tax IDs, and multiple facilities, this created an incredibly complex process.
Leveraging OrboGraph’s neural network technology, their clients have the ability to work with any bank and offer decentralized health systems a path to uniform processes, enabling them to adapt to a changing reimbursement environment and eliminating manual efforts around EOB scanning and image transmission. Now, their data flow works seamlessly for the hospital customer.
OrboGraph effectively functions as a payer in their network. Data flow works seamlessly for the end hospital customer thanks to the use of a Large Central Aggregator (LCA). In the LCA configuration, a provider (or bank partner) scans paper EOBs and electronically transmits through a lockbox adapter, replacing the work of manual processing or outsourcing. This approach is flexible enough to adapt to any medical lockbox servicing a hospital or system while still providing the benefits of removing manual effort associated with EOB scanning and image transmission.
OrboGraph’s solution facilitates a centralized approach to EOB conversion, functioning as a “traffic manager,” replacing disparate relationships with each client. The organization works with a central pipeline to control streaming of all client work while receiving results -- enabling dissemination and routing of results to each respective client. Additionally, correspondence letters are now automatically indexed and categorized, create the ability for clients to assign letters to users, add free-text comments, update the status of working letters, and even assign a customizable “last action” for tracking purposes.
Their new approach has resulted in both a revenue opportunity and a chance to expand and complete their product offerings.