The challenge: Increased claim denials and declining revenues prevent clinical expansion
Our client is a critical access hospital (CAH) with 22 acute care beds serving a rural southeastern US community. Its smaller size did not prevent our client from setting big goals, such as opening a much-needed oncology clinic. However, the hospital’s revenues had dropped, mainly due to increasing claims payment delays and denials. That made it virtually impossible to fund the new facility. Its thin staff of revenue cycle management (RCM) professionals could not effectively manage denials or pursue outstanding receivables. Finally, the director of patient financial services was retiring, and few applicants were interested in moving to the hospital’s beautiful but remote location. The hospital realized it needed help to quickly improve its revenue realization and support its vision for community care and reached out to Firstsource.
The solution: Turn revenue cycle management operations over to Firstsource
We implemented our total hospital business management outsourcing solution for our client. We first engaged an independent consultant to assess the hospital’s RCM processes and identify pain points. These became priorities for the Firstsource team to solve as it took over management of the hospital’s middle and back office revenue cycle management functions. Our solution encompasses claims submission, patient billing, accounts receivable management, denials management, cash posting and patient collections.
Through our expertise in working with critical access hospitals, we were already aligned with the unique requirements of this program. The CAH expertise as well as our proven RCM processes and transition methods enabled us to implement our solution in just 77 days, almost two weeks faster than the agreed-on 90-day implementation deadline. Within 90 days of our go-live date, we enabled our client to collect monthly revenue that surpassed all previous monthly revenue rates in the hospital’s history.
The results: Multiple forces move the revenue needle
Rural providers operate on very thin margins, and our client was no exception. However, the hospital understood how our solution and fast implementation would help it quickly achieve greater financial flexibility and improve its ability to serve its community. Our experience in managing reimbursements under CAH requirements was also important to our client’s decision to work with Firstsource.
Our proprietary workflow tool enables the Firstsource team to efficiently work claims and quickly spot trends, such as a single payer denying all claims with a specific code. With that information, we can then quickly uncover root causes of denied claims so the hospital can correct processes as needed or we can appeal denials armed with data showing payer error.
With Firstsource managing its back office, our client has been  free to shift and retrain its RCM staff to take on important patient-facing functions that had gone unfilled because of the difficulty of attracting talent to the client’s rural location. Now the hospital’s staff have the time to work on patient access, including billing estimates, financial counseling, pre-service and POS collections. The staff routinely screen every patient to understand what coverage they have or are eligible for, request payment and create payment plans. This work has resulted in pre-service and POS payments that our client simply could not pursue before.
In addition, as a major healthcare industry service provider, Firstsource amplifies the voices of our many rural and critical access hospital clients. We advocate effectively for all our rural clients when we approach a large payer to work on outstanding claims, appeal denials and correct process issues.
Our client’s patient-facing activities and our back-office work combine for a direct impact on revenue realization and on more efficient operations, such as clean claims rate. Our comprehensive reporting keeps our client’s CFO fully informed about trends and results, including cash collections at the point of service, discharges not final billed, inventory above 90 days and more. We continue to streamline processes, with the goal of achieving HFMA benchmarks. To date, the solution has improved our client’s cash flow and financial flexibility, enabling it to launch its long-envisioned oncology clinic.
