Client: One of the largest integrated health care delivery and financing systems in America.
Challenge: Legacy business rule obstructed claims processing and delayed revenue realization.
Solution: Implement an Agile methodology to make legacy rules smaller and more focused.
Results: 40% reduction of work, $400,000 annual projected savings, earlier implementation of solutions.
For hospitals providing critical care, one of the most pressing problems is revenue capture. Medical procedures cost thousands of dollars to implement, and hospitals rely on reimbursements from insurance companies to offset their operating costs and enable them to continue serving communities.
Sometimes insurance companies reject the validity of provider claims and refuse to pay for performed procedures. This could occur for several reasons, but some of the most common causes of claim denials are simple typos, clerical mistakes, and coding errors in the outgoing claims summary.
To avoid these types of claim denials, Lumevity’s client employs a revenue cycle management team that conducts pre-bill reviews. Auditing and correcting simple clerical errors before the claim is sent to payors, the revenue cycle team helps reduce preventable denials and increase timely payment.
The team used an automated pre-bill review program, however, that frequently halted the processing of certain claims. An overly complicated rule in the program’s code-script made the process unnecessarily complex and cumbersome. Requiring manual effort to locate and address, these stoppages caused delays in the work queue and prevented the timely collection of revenue from payors.
The claims team knew it needed to rewrite the logic in the rule to prevent unnecessary stoppages. Adjusting the rule required both granular medical coding knowledge and specific experience with information technology, and they struggled to gather the right resources to address the delays.
The claims team asked Lumevity to conduct an Agile workshop and help solve the problem.
Applying Agile principles and a rapid improvement mindset to the problem, Lumevity worked with the claims team to analyze stoppages and dissect the overly intricate rule.
Both a mindset and a set of collaborative practices, Agile improves operational execution and enables faster product and service development by breaking large, complex problems into smaller units. That’s exactly what Lumevity and the claims team did here. By analyzing the work queue and pinpointing exactly what part of the rule was causing each stoppage, the claims team was able to transform one 100-component rule into 18 simpler rules that reduced logical obstacles and expedited the claims process.
The Agile methodology also thrives on constant iteration and reflection-based adaptation – at each stage of the development journey, Agile designers analyze their work and use their findings to adjust their process going forward. The claims team applied this growth-oriented mindset to their workshop, and it brought them unprecedented success, both in the claims process redesign and beyond. During the workshop, the team paused to reflect on its own work and improve its process iteratively, avoiding potential problems down the line. The team also pledged to incorporate this iterative mindset into their overall workflow – now, they can apply Agile principles to projects and problems in the future.
One of Lumevity’s fundamental goals is to leave the customer in a stronger, more self-sustaining position than before. Lumevity isn’t there to do the work for customers – we’re there to enable customers to do their own work better. That’s exactly what happened here with the client’s claims team.
40% work reduction
Without unnecessary stoppages requiring manual review, the new claims process generated a 40% reduction in work – now, the claims team has more time to devote to more complex, interesting, and satisfying tasks.
Projected $400K annual cost savings
Now that the review process isn’t delaying claims approval, the new workflow is projected to improve revenue collection and save the client $400,000 annually.
A self-sustaining team
The Agile workshop gave the claims team the ability to self-diagnose problems and the tools to efficiently and effectively address them – now and in the future.