The Challenge

The leading healthcare company faced a significant challenge in their revenue cycle management. They needed to file claims to Payers for the healthcare services they provided. However, the complex process involved various data-dependent factors such as care coordination activities, patient eligibility, ICD-10 codes, supervising providers, CPT codes, modifiers, and units. This intricate process often resulted in filtered-out activities or patients, leading to a decreased number of filed claims and revenue loss.

The Solution

FulzTech implemented a multi-pronged solution to address this challenge. We introduced an approach where raw data was provided to the revenue cycle manager for finalization before bulk claim automation. If the target counts were not met, the missing and causal data points were identified and presented in email notifications along with their root causes.

An Azure Data Factory pipeline was established to generate raw data and send email notifications regarding missing causal data. The initial run was scheduled for the 1st of every month, with subsequent runs being manual but manageable by the revenue cycle manager. Once the data was finalized, the revenue cycle manager triggered an Azure Logic App workflow that filed claims in bulk.

The pipeline meticulously checked various factors, including patient eligibility, active care plans, availability of ICD-10 codes, compatibility of CPT codes with modifiers, and adherence to unit thresholds. Any missing or inadequate data points would result in the filtering of activities or patients. The unit calculation logic was implemented through an Azure SQL stored procedure, while the necessary data extraction programs were developed using Azure Logic Apps.

The Result

Thanks to FulzTech’s solution, the revenue cycle manager could proactively address missing causal data points received in email notifications at every stage. With full control over the entire process, the manager significantly improved claims filing yield, effectively preventing revenue loss. This successful partnership between FulzTech and the leading healthcare customer not only optimized their revenue cycle but also ensured they met their financial targets consistently.

This client success story showcases how FulzTech’s innovative approach in data management and automation transformed the revenue cycle for a leading healthcare company, leading to improved financial outcomes.

Tools and Platforms Used