Revenue Cycle Management Platform

The Issue 

The home health care billing (claims to insurance providers) has been carried out by means of legacy software and spreadsheets which were subsequently printed, emailed, and faxed to the insurance providers. The top challenges with these processes were: 

1. Three dedicated people working for a total of 80 hours every week to complete the billing for the previous week 
2. Manual errors and the time needed to re-do and re-submit the claims 
3. Delays caused by manual process, claim corrections 
4. Lack of visibility of accounts receivables 

Solution 

A detailed requirement gathering (discovery workshop) and analysis of short-term, long-term goals, target users, security, and scalability requirements were done. Once the problems and objectives were clear we applied design thinking principles to architect and design the solution.  

The task was to develop an automated, scalable, modular, configurable, secure, multi-tenant application that is easy to use. The first step was to develop a robust core which was an intelligent automation engine. Then we developed modular services around the engine with features to configure rules specific to the payers, patients, patient authorizations, different EDI output formats (ANSI 837, CMS1500, UB04), output delivery channels, dashboard, alerts, notifications, and role-based access control.  

The solution had an exclusive connector module to integrate with different third-party scheduling systems (for schedule, patient details, and details of services provided), clearinghouses, EVV aggregators, QuickBooks®, Fax, and email.  

The platform was HIPAA compliant, used oAuth based authentication, had role-based access control, user-friendly error messages, detailed activity log, PHI data in rest were encrypted and data in transit were secured with SSL.  

The solution was deployed on hardened AWS cloud with HA, load balancing with monitoring, and required network security policies. 

 Top 5 Benefits 

1. The time taken for claim creation to submission process reduced from x3 people working for 5 days to <15 minutes for weekly claim processing 
2. Reduced the errors in claims by >70%, Claim correction and re-submission time has been reduced by over 400% 
3. Dashboard with claim details provided, visibility of the claim’s status and account receivables, extensive reporting with valuable insights useful for key business decisions 
4. Minimized lost revenues and faster collections 
5. Big savings in manpower, time, and cost