Anomaly Detection in the Revenue Cycle – Take Command of You Data

Thumbnail Anomaly Detection

Being a health system CFO isn’t very much fun these days.  Health care organizations are cash strapped and being asked to do more with less across both the clinical and administrative landscapes.  Something has got to give.  There has to be a solution that delivers better efficiency and increased yield without reliance on IT and years long projects and implementations.  Enter anomaly detection.

It’s why they are called anomalies.  They’re occurrences that are outside of what is normal, standard or expected.  While there are some universal truths in revenue cycle management, anomalies definitely occur.  The challenge lies in finding them in a timely manner, whether they are hidden, lost or overlooked.  And then creating the opportunity to resolve those accounts and collect the dollars associated with them to optimize net revenue.

We looked at 14 large health care organizations with varying EMR’s including Cerner, Epic, MEDITECH and others, situated throughout the country and ranging in net patient revenue from $400M to $15B. Our experts looked at about fifty different algorithms to identify possible anomalies causing problems in the revenue cycle.  The team evaluated the data and found the top 5 algorithms produced an average of $12M in recoverable dollars at EACH health system.

What made the exercise more interesting was that the challenges that each organization faced were different.  While there was commonality in that all of the organizations had significant opportunities to improve their management of self-pay accounts, the collectible dollars averaged around $280 per account.  In one organization with less than $1B in net patient revenue, we identified a coding error that resulted in a potential $54M recovery opportunity.  And finally, there were organizations that clearly had revenue cycle process improvement opportunities related to accounts billed but not worked.  It didn’t occur in every organization, but when it was a problem there was an average $13M recovery opportunity. 

In each case, we helped these organizations take command of their data and begin to address the problems they were facing with a technology enabled services approach.  As healthcare organizations continue to experience unprecedented financial pressures and negative operating margins, this type of prospective analysis is no longer a nice to have, but a must do.  We prove our value by delivering an ROI, not an IOU with our solutions and services.

Interested in learning more? The team at VisiQuate is focusing on how we can help hospitals optimize their revenue cycle management. Visit our Revenue Cycle Playbook for step-by-step plays to help you stay on top of the ever-changing landscape of healthcare revenue cycle, or contact us to schedule a demo.

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