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Case study

The challenge

MetroHealth, a large, safety-net healthcare system in Ohio, and Cognizant have collaborated on revenue cycle solutions since 2013. Both partners identified the need to mitigate spikes in claims denials by payers, shorten accounts receivables days, and increase cash collections. One critical issue was a lack of integration between MetroHealth’s upstream and downstream systems that made it difficult to identify the root causes of pending or denied claims. For example, an incorrect benefits eligibility confirmation or missing preauthorization can cause a health insurer to deny payment on a claim. MetroHealth also wanted more transparent processes across departments, such as provider enrollment, patient registration and coding, in order to identify and solve issues.

Our approach

MetroHealth identified automation as key to preventing denials before they occur and creating optimal workflows for tracking outstanding claims with health insurers. To accomplish this, the Cognizant and MetroHealth revenue cycle management teams worked to launch the Cognizant® Revenue Cycle Management Workflow solution (CRCM Workflow). The solution allows MetroHealth to examine any point across its entire revenue cycle.

CRCM Workflow prioritizes eligible accounts to address using business rules based on payer, amount and age. CRCM Workflow also works to prevent denials with TriZetto® Advanced Reimbursement Manager (ARM) Pro denials management solution. ARM Pro automates the previously manual process of identifying common causes of claim rejections. This information allows MetroHealth and Cognizant to collaborate on denial prevention plans and assist affected departments in implementing them.

Cognizant also assisted MetroHealth to identify underpayment and nonpayment from payers. For example, a large payer was unresponsive to over 5,000 of MetroHealth’s account claims, the Cognizant team identified these accounts, MetroHealth alerted the payer, and the accounts were processed. 

CRCM workflow reclaims time, nets revenue

With CRCM Workflow, ARM Pro and the Cognizant Revenue Cycle Management services team, MetroHealth and Cognizant have identified other process issues within its systems that can result in pending or denied medical claims, such as how patient observation hours are entered into MetroHealth’s electronic health record system. That fix required creating a rule to ensure hours are reported per date of service, not as a whole, to help avoid denials by Medicaid managed care plans. These types of solutions throughout and beyond the revenue cycle resulted in a 30% decrease in the number of denied claims, netting the company $13M in additional revenue over a one-year period. The average collections per day increased by 25% from Q1 to Q4 in a single year. By improving processes that affect timely payment of its claims, MetroHealth is delivering a better financial experience to patients. 

$13M

additional revenue over one year

25%

Increase in average daily collections

8%

Increase in average productivity