Workflow Automation in Atlanta, GA

Healthcare / Revenue Cycle Management

A healthcare organisation in Atlanta (3 hospitals, 42 outpatient clinics, 1,600 providers, 2.2M annual encounters, $3.4B annual revenue, 280 revenue cycle staff) was losing revenue and efficiency through manual revenue cycle processes that had not kept pace with the organisation's growth. Revenue cycle problems: (1) claim submission delay — charges from clinical encounters taking an average of 4.8 days to reach clean claim submission — moving manually through charge capture, coding review, coding correction, and claim scrubbing. Each day of delay: costing the organisation in accounts receivable carrying cost and occasional timely filing deadline misses. Claims missing timely filing deadlines: averaging 340 per month ($680K/month in forfeited revenue), (2) denial accumulation — denied claims accumulating in work queues with an average of 28 days from denial receipt to appeal or correction submission. Denial volume: 18,400 per month (14.2% denial rate). Manual process: denials arriving via EOB and ERA, manually categorised, manually assigned to staff, and manually appealed. The accumulation: $4.2M in denied claims at any time sitting in work queues — many exceeding the appeal deadline by the time they were worked, (3) eligibility verification gaps — insurance eligibility verified for 72% of appointments — the other 28% verified at check-in or not at all. The gap: 8% of claims denied for eligibility issues (wrong insurance, coverage terminated, authorisation required) that could have been identified before the visit. Eligibility denial cost: $2.1M annually in preventable denials, (4) payment posting backlog — electronic and paper payments requiring 3-5 business days to post. Manual process: payment staff receiving EOBs/ERAs, identifying the correct patient account, matching the payment to charges, and posting adjustments. Backlog: $12M in unposted payments at any time. The backlog: financial reports showing receivables that had actually been paid but not yet posted — misleading financial visibility and delayed collections follow-up, and (5) manual handoff failures — work passing between teams (registration, coding, billing, collections) through email, shared folders, and informal communication. Handoff failure rate: an estimated 6% of work items lost or significantly delayed during handoffs. The failures: claims that should have been worked sitting in email inboxes, shared drives, or physical in-baskets — invisible to management until they became problems.

We built comprehensive revenue cycle workflow automation over 14 weeks. Pre-visit automation (weeks 1-5). Automated eligibility verification: insurance eligibility automatically verified 72 hours before every scheduled appointment — the system checking coverage status, benefits, copay/coinsurance, and authorisation requirements. Verification failures: automatically triggering patient outreach (phone or text) to update insurance information before the visit. Authorisation automation: when eligibility verification identified authorisation requirements, the system automatically initiating the authorisation workflow — clinical documentation assembled, authorisation request submitted to the payer, and status tracked through approval. The automation: authorisation obtained before the visit rather than discovered at check-in. Financial clearance: patients with outstanding balances, high copays, or financial assistance needs identified before their appointment — enabling financial counselling before the visit rather than surprise bills afterward. The clearance: reducing patient financial complaints and improving point-of-service collection. Charge-to-claim automation (weeks 3-9). Automated charge capture: clinical documentation events triggering automatic charge capture — procedures documented in the EMR automatically generating charges based on configured charge rules. The capture: charges generated within hours of service rather than waiting for manual review. Coding workflow: charges routed to the appropriate coding queue based on service type and complexity — routine encounters auto-coded with rule-based logic, complex encounters routed to certified coders with AI-suggested codes and supporting documentation highlighted. The workflow: coding completed within 24 hours of service for routine encounters. Claim scrubbing and submission: coded charges automatically scrubbed against payer-specific rules — common denial triggers identified and corrected before submission. Clean claims: submitted automatically to clearinghouses. Claims requiring human review: routed with specific error descriptions. The scrubbing: clean claims submitted within 24 hours of coding completion. Denial management automation (weeks 5-11). Automated denial intake: denial information from EOBs and ERAs automatically parsed — denial reason codes mapped to denial categories, root cause determined, and the denial routed to the appropriate resolution workflow. The intake: denials categorised and routed within hours of receipt rather than days of manual processing. Resolution workflow: each denial category following an automated resolution path — eligibility denials triggering re-verification and corrected claim submission. Coding denials: triggering coder review with the specific issue identified. Authorisation denials: triggering authorisation pursuit or retrospective authorisation request. Medical necessity denials: triggering clinical documentation review and appeal letter generation. The workflow: denial-specific resolution rather than a generic work queue. Appeal automation: appeal letters generated automatically from templates with case-specific clinical documentation — the letter, supporting documentation, and submission compiled and sent to the payer within the appeal deadline. The automation: appeals filed promptly with the documentation that increases the likelihood of reversal. Payment posting automation (weeks 8-14). ERA auto-posting: electronic remittance automatically matched to claims and posted — payment amounts, contractual adjustments, and patient responsibility calculated and applied. Exception routing: payments that could not be automatically matched routed for manual review with the specific matching issue identified. The posting: 85% of electronic payments posted automatically within hours of receipt. Underpayment detection: automated comparison of payment against contracted rates — underpayments identified, quantified, and queued for follow-up. The detection: underpayments caught systematically rather than discovered sporadically. Patient balance workflow: after insurance payment posting, patient balances automatically calculated and patient statements generated — the billing cycle completing without manual calculation or statement preparation. The workflow: patient bills sent within 48 hours of insurance payment rather than the 2-3 week manual process.

The revenue cycle automation deployed across the organisation within 16 weeks. Claim submission speed: charge-to-clean-claim time: from 4.8 days to 1.2 days — 75% reduction. Timely filing deadline misses: from 340/month to under 20/month — 94% reduction. Revenue recovered from eliminated timely filing misses: $7.8M annually. Denial management: denial work queue: from 28-day average to 5-day average for resolution. Denials exceeding appeal deadline: from 22% to under 3%. Denial rate: from 14.2% to 9.8% — pre-visit eligibility verification and claim scrubbing preventing denials. Appeal success rate: from 34% to 58% — timely, well-documented appeals reversing more denials. Revenue recovered from improved denial management: $8.4M annually. Eligibility verification: pre-visit verification rate: from 72% to 98%. Eligibility-related denials: reduced 78% — issues identified and resolved before the visit. Revenue recovered from eligibility denial prevention: $1.64M annually. Payment posting: payment posting time: from 3-5 days to same-day for electronic payments. Auto-posting rate: 85% of electronic payments posted without manual intervention. Unposted payment backlog: from $12M to under $1.5M at any time. Financial report accuracy: dramatically improved with same-day posting. Staff efficiency: revenue cycle staff redeployment: 42 of 280 staff (15%) redeployed from manual processing to analytics, process improvement, and complex case management. Staff satisfaction: improved from 3.0/5 to 4.1/5 — automation eliminating the repetitive tasks that caused burnout. Handoff failures: from 6% to under 0.5% — automated workflow routing eliminating the email and shared-folder handoffs where work was lost. Financial results: timely filing revenue recovery: $7.8M/year. Denial management improvement: $8.4M/year. Eligibility denial prevention: $1.64M/year. Payment posting acceleration: $2.1M/year (faster collection). Staff efficiency redeployment: $3.2M/year. Total annual impact: $23.14M/year. Workflow automation development: $680,000. Annual operations: $96,000/year. First-year ROI: 3,303%.