Operational and Revenue Optimization for a Specialty Hospital
Organization & Engagement Overview
Hospital Profile
- Specialty hospital focused on substance detox services
- High-value patient demographic with complex payer mix
- Critical need for operational alignment across teams
- Challenged by cash flow issues despite strong clinical services
Engagement Scope
- RCM & UM Department leadership integration
- Revenue cycle optimization across all payers
- Utilization management process improvements
- Audit success and payer relationship management
The Challenge
Despite providing high-value substance detox services, the hospital was experiencing critical cash flow issues driven by operational misalignment across revenue cycle, utilization management, and clinical teams.
Inconsistent Billing Submissions
Incorrect claims to Medicare and commercial payers causing cash flow delays
DRG Optimization Failures
Inability to maximize DRG reimbursement due to coding and operational inefficiencies
Payer Compliance Issues
Difficulty tracking and submitting compliant claims based on payor-specific requirements
Team Misalignment
Lack of alignment between clinical, RCM, and UM workflows hindering accurate reimbursement
Our Integrated Solution
We integrated hands-on leadership across RCM, Admissions, and Utilization Management to ensure seamless collaboration from patient referral through claims submission.
Track 1: Clinical Alignment
Documentation Optimization
Maximize clinical data for DRG coding
UM Process Integration
Align utilization review with billing workflows
Denial Prevention
Address clinical gaps before claim submission
Compliance Assurance
Audit readiness and payer requirement adherence
Track 2: Revenue Optimization
RCM Leadership Integration
Direct oversight of billing operations
Claims Submission Excellence
Accurate, timely claims to all payers
Payer Relationship Management
Strengthen payee relationships and communication
Cash Flow Recovery
Maximize collections and minimize denials
Key Deliverables
| Deliverable | Immediate Impact | Long-Term Value |
|---|---|---|
| RCM & UM Department Leadership | Departments operated seamlessly | Sustained operational excellence |
| Revenue Cycle Optimization | Improved cash flow & accuracy | Predictable, maximized reimbursement |
| Audit Success ($800K Impact) | Prevented major payer take-backs | Maintained compliance & reputation |
| Referral Process Redesign | Reduced wait times | Increased complex insurance access |
| DRG Optimization | Enhanced coding accuracy | Maximized reimbursement potential |
Measurable Results
Increased Cash Flow
Improved claims submission processes leading to higher cash flow and reduced errors
Zero Payer Take-Backs
Successfully passed major audit preventing $800K in potential take-backs
High Compliance Standards
Implemented improvements reducing denials and maximizing reimbursement
Sustained High Census
Optimized referral process maintaining near 100% census with complex insurance patients
Why This Strategy Worked
Success came from integrating into day-to-day operations and ensuring RCM and UM teams worked together to optimize reimbursement and maintain compliance. We aligned clinical practices with financial goals, ensuring every step from admission to billing submission was fully optimized.
Rather than focusing only on backend claims, we embedded in the workflows of the organization, removing barriers across departments and unlocking cash flow that had been trapped by operational inefficiencies.