Background

Tegria and a large healthcare system in the southwest established a partnership over two years ago (2020) when preparing to go-live with a new EHR. The goal was to establish a plan to minimize financial risks, mitigate challenges, stabilize during and after go-live, and return to organizational baselines as soon as possible. After making it through go-live (and a pandemic!), the organization was ready to begin optimizing their new system.

After a successful first engagement, Tegria returned to assist with optimization and automation opportunities. The second engagement was divided into three distinct sprints which focused on many challenging issues that included:

• Duplicate claims denials
• Eligibility rejections
• Credit profile and undistributed credits
• Global period and bundling

The overall goal of this engagement was to identify optimization opportunities associated with the aforementioned areas of focus, let the system serve as “first line of defense,” and automate processes wherever possible to allow staff to focus on truly challenging issues.

Methodology

Tegria used three distinct sprints, each four weeks long, to address the areas of focus. Each sprint involved focused discovery, problem solving, validation, and finalization. Staff shadowing, discovery sessions, and in-depth system review were critical components to each sprint. Leadership and end-users from respective areas of focus were made available to Tegria, which was invaluable throughout the project. Over the course of the project, a detailed Findings and Recommendations list was created, outlining 50+ items for current or future optimization sprints. Bringing Operations and IT together helped paint the “full picture” and ensured a comprehensive, historical understanding of issues. Lastly, all build-related solutions were reviewed with and approved by the healthcare’s IT leaders before being implemented.

Key Activities

Key Results

Duplicate Claim Denials

• 2% reduction in overall denials
• 375-hour productivity gain due to automation
• 7.6% reduction in duplicate denials monthly average (Q2 – Q3 2022)
• 321% increase in secondary claims properly submitted and auto accepted

Eligibility Rejections

• 329% increase in coverages found in Q3 of 2022 with connectivity batch job
• 2637% increase in coverages found in Q3 of 2022 with self-pay batch expansion
• 5% productivity gain (1 day/month) by automating coverage scanning – decreased manual effort
• 8+ hour weekly productivity gain due to automation

Credit Profile

• 2% reduction in self-pay WQ volume with updated rule logic
• 4% increase in self-pay credits automatically resolved – Gold medal status
• 250+ hour productivity gain expected with resolution of inappropriate refund requests
• $1.06 million increase in records routing to correct WQ

Bundling/Global

• 3.5% reduction in EKG-related denials
• 3.25% reduction in global period denials 
• > 1,000 denials prevented with system enhancements