CASE STUDY
Ensemble’s secondary zero-balance review yields $13M in recoveries.
Proactive strategy employing AI and anomaly detection prevents future underpayments.
SNAPSHOT
A Midwestern health system needed a secondary partner to identify and recover revenue from underpaying accounts. It felt this was an important and untapped revenue opportunity not covered by its primary underpayment vendor.
PROFILE
- Nonprofit, 10+ hospitals
- $1B+ NPR
- Midwest
- Underpayment recovery secondary partner
Challenges
The system’s primary vendor focused only on high-value claims and significant variances, neglecting accounts with zero balances. Additionally, deviations from contracts and statutes were not identified, raising concerns about comprehensive revenue capture and compliance. Finally, a lack of standardized processes and data-driven intelligence made it challenging to identify and prevent future underpaid claims stemming from errors in coding, charging, billing or payer processes.
Solutions
Leveraging Ensemble’s AI-infused analytics, expertise and best practices, the health system recovered significant revenue from previously unidentified opportunities. More importantly, process improvements were put in place to prevent future underpayments, increasing revenue collection and cash flow. As part of these efforts, we:
- Created billing edits to fix revenue coding errors causing underpayments
- Built prediction rules using AI automation to prevent payer issues and detect coding, charging and billing errors
- Investigated and challenged contract language with specific payers to unlock additional revenue
- Led contractual dispute against a payer for implant underpayments
Results
opportunities identified
medications found
discovered