P R O B L E M S T A T E M E N T
The client, a mid-sized healthcare facility, was grappling with a high denial rate for their insurance
claims. Despite their best efforts, a substantial percentage of claims were being rejected or denied by
insurance payers. This situation not only hampered the facility’s revenue stream but also put a strain on
their administrative resources.
FINDINGS
QWay Healthcare conducted a thorough assessment of the client’s RCM processes and identified key
findings:
Data Analysis: A significant portion of denials were attributed to incorrect patient information, coding errors, and missing documentation.
Lack of Automation: Manual data entry and claim submission processes were prone to errors and inefficiencies.
Limited Denial Insights: The client lacked a robust system to track and analyze denial patterns,
hindering the ability to make informed decisions.
OUTCOMES
QWay Healthcare achieved a 65% decrease in the denial inventory within 6 months and achieved net collections of $1 million on a balance of $2 million. Additionally, the health system achieved a 40% cost savings from outsourcing coding denial management to QWay Healthcare
A T A G L A N C E
CH A L L E NGES
Lack of visibility
Manual Processes
Complex payer guidelines
Inadequate follow-ups
B E N E F I T S
Process Automation
QWay implemented automated systems for data entry, claim submission, and verification, reducing human errors and expediting the entire claims process.
Payer Guidelines Integration
QWay integrated the diverse payer guidelines into the facility’s workflow, ensuring accurate claim submissions.
Denial Analysis Tool
QWay introduced a powerful denial analytics tool that identified recurring denial reasons, allowing the facility to address root causes systematically.
Follow-up Protocols
QWay established a streamlined follow-up protocol to address denied claims promptly, correcting errors and resubmitting claims within stipulated timelines.
65%
Denial Rate Reduction within 6 months with frequent reviews of the usage of the appropriate usage of coding and payer guidelines.
40%
Cost reduction by hiring mobile workforce provided by QWay Healthcare for denial management services.
Key takeaways from this engagement
Each problem found in the assessment was matched to a specific fix:
- Incorrect patient information was addressed at registration, with demographic and eligibility verification before claims were created.
- Coding errors and missing documentation were caught before submission through coding review and documentation follow-up.
- Manual data entry and submission were replaced with automated data entry, claim submission and verification, reducing keying errors and delays.
- Limited denial insight was solved by tracking denials by payer and reason, so recurring causes could be fixed at the source.
The same sequence — assess the data, fix front-end causes, automate repetitive steps and track denials by cause — applies to most organizations facing rising denials. Learn more about QWay Healthcare’s denial management services and other case studies.