Case Study
How MDaudit Denials Predictor Helped a Faith-based, Nonprofit Integrated Health System Identify and Mitigate up to $10M in Revenue Risk
Facing increased Medicare RAC audit scrutiny and a shrinking compliance team, this faith-based nonprofit health system needed a way to identify denial risk and its root causes before claims went out the door, without adding headcount.
Background Summary
Faith-based health system uses Denials Predictor to flag revenue risk before claims leave the door.
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See how MDaudit Denials Predictor helped a faith-based, nonprofit health system identify and mitigate up to $10M in revenue risk.
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The Customer Profile
This customer is a faith-based, nonprofit integrated health system serving more than 80 communities across Oregon, California, and Hawaii, with 37,000 employees, providers, and volunteers delivering care across more than 400 sites, including 19 acute care and five critical access hospitals, clinics, hospice and home care agencies, and retirement centers.
The Solution
MDaudit Denials Predictor helps identify denial risk and its root causes, even before payer adjudication, to decrease denials, shorten payment lag time, and increase cash flow. Using a custom rule built on MDaudit’s payer-centric rules engine, the team flags accounts that fall under the Medicare Coverage Evidence Development (CED) program before claims go out the door.
- Custom payer-centric rules stop claims lacking a required CED designation before submission
- Ad hoc reports and Denial Risks shift the team’s focus from after-the-fact auditing to root-cause analysis
- Broader denial-type visibility (compliance issues, medical necessity, additional documentation required, and more) helps decrease financial risk
The Results
- Identified nearly 23% more revenue year over year, despite fewer auditors
- Decreased compliance risk identified by over 20%
- Drove a downward trend in denials and an upward trend in reimbursement
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