MD Clarity Helps a Large Orthopedics Group Find Over $10 Million in Underpayments and Automate Inefficient Workflows

The Summary

The Situation

Manual workflows, disconnected systems, complex payer agreements, and changing patient benefits requirements put a strain on operational efficiencies of a large orthopedics group, a 120+ physician practice with 30 locations and two Ambulatory Surgery Centers in the area. With a growing volume of patients flowing through many locations each day, “the practice was looking for a single solution to help manage their insurance contracts and patient benefits to ensure optimal collections from patients and payers”, said the Patient Accounts Manager.

The orthopedics group had a strategic goal to establish a scalable process to share accurate costs with patients before surgeries, while also ensuring they were getting paid correctly by insurers. In order to achieve this goal, they needed to integrate their patient benefits and pricing into a single, reliable, automated workflow that connected both their front-end and back-end teams.

“The practice needs a single solution to manage and audit their insurance contracts and capture front-end data needed to ensure proper collections from patients and payers.”

- Business Office Director

The Challenge

The group found it challenging to keep up with the ever-changing nature of payer agreements and turned to multiple excel spreadsheets and manual calculations to determine patient benefit eligibility while setting up patient appointments. These manual front-end tasks left staff feeling time strained, paving the way for human error and a complicated and lengthy back-end revenue cycle. “We had different contract spreadsheets for providing patient estimates that coders needed to be able access to determine what the allowable was, and then apply additional calculations to ensure accuracy,” said the Business Office Director.

“They were using multiple spreadsheets and websites to determine eligibility and costs while on the phone trying to schedule patients.”

These manual processes led to errors with prior authorizations, coverage-related denials, and an inability to effectively collect payments from patients upfront, resulting in long costly collections cycles from insurers and patients.

This manual approach to benefits eligibility fell short for a number of reasons:

  • Staff had to manually key patient information into their real-time-eligibility solution
  • Staff didn’t have capacity to check benefits for every patient visit
  • As a result of not checking benefits for every visit, they were experiencing denials for lack of coverage
  • Medicaid coverage changed month-to-month causing an inability for staff to keep up
  • Group had no way to identify the plan-specific attributes of each patient that drive accurate referral, authorization, and billing

On the back-end, they did not have a system to ensure they were getting the most out of their payer contracts.

With such a large and geographically diverse practice, this orthopedics group needed a consistent, and trusted source to manage and analyze all of their insurance contracts.

As the group grew, the problems magnified, and they quickly realized they needed a single, cost-efficient, and scalable solution to help them gain efficiencies on both the front and back end of the revenue cycle.

“The MD Clarity tool allows us to ensure that all claims are reimbursed at the appropriate contracted rates.”

- Patient Accounts Manager

The Solution

The orthopedics group began searching for a solution that could create a single, automated workflow for managing patient benefits eligibility checks upfront while providing the most accurate pricing data to patients. “We were looking for an affordable solution that met our specific needs that could scale as we did, ”said the Business Office Director. Ultimately MD Clarity’s solution best met their needs.

Today, each patient is provided an accurate estimate of their financial responsibility while an appointment is being made. Armed with MD Clarity’s proprietary pricing engine, the group’s front-end staff are able to automatically determine allowed amounts in real time, accounting for CMS and payer rules, facility structure, and complex adjustments.

The ClarityFlow module has allowed their team to move to an exception-based workflow, eliminating manual data entry by integrating their scheduling data into an automated patient benefits engine. Today, over 95% of patient’s verifications are automated. Beyond just knowing if a patient’s coverage is active they can now efficiently detect and target the following for each patient without manual review:

  • Patients with wrong COB order
  • Patients with a Medicare Advantage plan when registered as Medicare
  • Patients with a commercial Medicaid plan when registered with state Medicaid
  • Patients with specific Group, Plan, or Primary Care providers that require follow-up on special workflow requirements
  • Patients with a different MemberID than what is currently on file

The Results

The implementation of MD Clarity’s solutions has led to big operational efficiencies on the front-end, and even bigger revenue gains on the back-end. Through proper contract analysis, MD Clarity has saved this orthopedics group over $10 million in underpayments alone. At the same time, front-end staff enjoy the increased automation of benefit eligibility checks and no longer waste valuable time manually calculating allowed amounts for each patient.

“We are very satisfied with the usefulness of this tool and are continuing to explore how this tool can assist us in other avenues of our business. "

- Patient Accounts Manager

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