Identifying Service Line Profitability Through Healthcare Analytics

Identifying Service Line Profitability Through Healthcare Analytics

SITUATION:

A leading U.S. hospital GPO management company provided end-to-end revenue cycle management services to over 3,000 hospitals, but was experiencing significant revenue loss due to underpayments and claims errors with no way to identify the source.

PLAN2ACCOUNT SOLUTION:

Phase 1:

Plan2Account performed a complete analysis on A/R metrics to identify all potential areas of revenue loss.

Phase 2:

Hospital management software was set up allowing for isolation of the major gaps and errors in the claims transmission process.

Phase 3:

Through targeted follow-ups, reimbursement trends were managed providing a complete cause analysis to reduce bad debt.

CLIENT RESULTS:

By partnering with Plan2Account, the client gained a guided business strategy allowing them to identify service line profitability and reduce overall revenue loss. The partnerships also allowed the client to successfully manage reimbursement trends and accelerate cash collections.

 

The client significantly reduced revenue loss and increased collections through Plan2Account identified opportunities.

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Millions Recovered For Expansive Hospital System Through Artificial Intelligence And Business Intelligence Software

Millions Recovered For Expansive Hospital System Through Artificial Intelligence And Business Intelligence Software

SITUATION:

An expansive $6 billion hospital system had a diverse Payor contract base and was unable to successfully monitor payment quality through reporting, therefore continuing to lose millions in underpayments. The client needed a solution for the continuous, systematic monitoring of contract payment quality and real-time alert reporting.

PLAN2ACCOUNT SOLUTION

Phase 1: Custom Data Sets Reverse Engineered

Plan2Account began by re-adjudicating all transactions going back 5 years with a 100% audit of payments.

Phase 2: Real-Time Payment Monitored

Through advanced AI and a predictive auditing and modeling process, Plan2Account set up automated contract auditing with real-time mistake identification before the Payor pays a claim.

Phase 3: Live Gathering of Data

Data from all units began compiling and reporting to a secure Plan2Account data center dedicated to the client.

Phase 4: Analyzed and Reported on Each Identified Code Issue

The reported, analyzed and archived data provided maps, charts and real-time alerts for speedy issue identification and resolution.

CLIENT RESULTS:

Plan2Account integrated an online access client dashboard ensuring real-time alerts of payment errors to assist decision making from any computer or smart device. This allowed the client to identify $100 million in payment errors and reduce future payment mistakes, increasing contract productivity and system sustainability.

 

Plan2Account secured Payor settlements of $30 million into the hospital system’s bank account.

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Predictive Modeling for Population Health Management

Predictive Modeling for Population Health Management

SITUATION:

A prominent healthcare organization based in the United States sought to improve the quality of patient care, reduce healthcare costs and better understand the health status of patients. They required a program to predict the future health status of patients and classify them by current health checks.

PLAN2ACCOUNT SOLUTION:

Phase 1:

Plan2Account began acquiring clinical, claim, socio-demographic and care management data across the care continuum to aggregate and standardize data.

Phase 2:

Plan2Account defined the target population and normalized all relevant patient data to analyze and stratify populations based on clinical, financial and demographic risk.

Phase 3:

Through the application of advanced predictive algorithms, Plan2Account determined probable clinical outcomes, cost of care and patient satisfaction while identifying areas for improvement.

CLIENT RESULTS:

Plan2Account provided convenient access to health information, with or without an EHR, including relevant alerts within the clinician’s natural workflow. The client in turn improved overall quality of patient care and enhanced patient experiences, while reducing health costs.

 

The client gained predictive healthcare algorithms that successfully reduced their health costs and improved their standard of care.

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Identifying Medicaid Fraud and Validating 3rd Party Payments Through Powerful Analytics

Identifying Medicaid Fraud and Validating 3rd Party Payments Through Powerful Analytics

SITUATION:

A Medicaid HMO required a claims audit and transactional review of a 40,000-patient base. They desired a vendor who could both audit and identify transactions matched to a referral from the primary care Electronic Medical Record (EMR) software system.

PLAN2ACCOUNT SOLUTION:

Phase 1:

Plan2Account performed a complete review of payment and EMR domains to identify key features pertaining to issues, which were listed out in their semantic variations.

Phase 2:

Search strategies going back 5 years from the dates of service were then formulated to identify recoveries and capture overpayments.

Phase 3:

Once fraud and non-continuity delivery domains were identified, Plan2Account developed a contract structure for categorizing provider information for relevant non-fraud applications.

Phase 4:

Plan2Account performed a population health strength analysis of the most active targets identified.

CLIENT RESULTS:

The client received a data-based strategy linking the referral process, claims payment and EMR software along with a complete fraud analysis of Medicaid industry issues. As a result, three primary care physicians were identified as fraudulently writing prescriptions, and further deceit was avoided.

 

Plan2Account validated 3rd party payments and recovered $3.5 million in overpayments for the client.

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Delivering Sustainable Revenue to a Leading Stop-Loss Carrier

Delivering Sustainable Revenue to a Leading Stop-Loss Carrier

SITUATION:

A leading German stop-loss insurance carrier with a presence in over 150 Managed Care Payors was struggling to avoid unnecessary overpayments and high-dollar stop-loss claims. They needed a process in place that could predict internal contract failures based on a live audit process and tests of each Payor component within the stop-loss contracts to avoid future costly mistakes.

PLAN2ACCOUNT SOLUTION:

Phase 1:

Plan2Account imported and merged data sets of the 150 Payors to rebuild the missing data.

Phase 2:

Data standardization, normalization, corrections, calculations, verifications and enrichments were performed.

Phase 3:

Transactions were tracked to contracts with payments and referral error accuracy on the basis of refined and processed data.

CLIENT RESULTS:

Plan2Account was able to identify the largest source of errors, calculate the efficiency losses in overpayments, and suggest improvements, including establishing a dashboard for problem resolution acceleration. Plan2Account provided easy access for monitoring and visualizing data through our proprietary auditing software, allowing the client to forecast payment mistakes in advance, saving potentially millions in overpayment losses.

 

The client reduced overpayments by 3.5%, resulting in increased revenue and stability.

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