Case Study
Fixing a Costly Billing File Error To Deliver Major Monthly Savings
- Challenge: Persistent billing file errors led to over $150,000 in monthly lost revenue and excessive manual cleanup work.
At a Glance
- Organization: Nonprofit health insurance provider
- Location: Midwestern U.S.
- Services Provided: Error analysis, root cause identification, backend fix, workflow improvements, validation testing
Key Outcomes
- Resolved a recurring billing file error affecting Enhanced Population Health payments
- Reduced monthly billing losses by $130,000
- Recovered an estimated $780,000 in missed revenue
- Eliminated the need for time-consuming manual error cleanup
This one fix had a huge impact—it improved efficiency and financial performance. Instead of a workaround, we uncovered the root cause and worked across the organization to improve our workflows. The results speak for themselves. This partnership has been a win.
CLIENT PROJECT LEAD
Background
A large Midwestern payer was grappling with a persistent billing challenge. For months, the organization had been experiencing high volumes of invalid billing rejections—particularly on its billing detail file, resulting in delayed or lost reimbursements. These rejections were tied to value-based payments’ not being accurately reflected, causing significant monthly revenue losses.
A short-term workaround was in place; but it demanded ongoing manual cleanup, adding operational inefficiencies to the financial strain.
Solution
Tegria partnered with the payer to first analyze the billing detail file and associated error logs. This analysis then led us to determine the need to investigate the main source of the errors. Through deep data analysis and collaboration with Finance and IT stakeholders, the team identified and addressed the root cause in the billing file generation process.
Approach:
- Analyzed historical billing detail file trends to quantify financial impact
- Identified the root cause for the data discrepancy
- Implemented a backend fix to correct the billing file logic and eliminate manual workaround
- Validated improvements through comparison of post-fix billing files
Results
The impact of the backend fix was immediate and significant. Monthly billing losses due to errors dropped from over $150,000 to just over $20,000—a reduction of nearly 87%. This improvement has allowed the payer to recover an estimated $780,000 in historical lost revenue.
Additionally, the fix has eliminated the need for manual cleanup of rejected bills, freeing up staff time for higher-value tasks and boosting overall operational efficiency.