CASE STUDY
84% denial reduction doubles hospital wound care capacity.
Southeastern hospital funds new medical equipment with revenue from decreased denials.
SNAPSHOT
A large faith-based health system faced high denial rates for specialized outpatient services. By pinpointing root cause issues, optimizing authorization workflows, strengthening clinical documentation and educating staff, Ensemble helped reduce first-pass denials by 84%.
The additional revenue gained from six months of accurate insurance payments funded two new specialty medical devices, doubling the patient treatment capacity at a wound care center. Building on this success, Ensemble worked across various outpatient departments to educate staff on best-practice denial intervention, leading to a 4.2% reduction in denials systemwide.
PROFILE
- Nonprofit health system
- $1B+ NPR
- Southeast
- End-to-end RCM partner
Challenges
“I got on the phone with the department head to listen to her concerns and understand her needs,” explained Nicole Hoehler, Process Improvement Advisor at Ensemble. “The department was staffed with expert clinicians who specialized in wound care treatment, not denials management. They didn’t have the resources to analyze denial trends for root cause issues or redesign systems and workflows to meet changing payer requirements. As a result, they weren’t being paid fully by insurance companies for the necessary care they were delivering. We came in to fix that.”
Solutions
“These weren’t claims being denied because the services were unnecessary or invalid under the payers’ coverage policy. They were just being submitted in a way that didn’t meet the payers’ requirements,” said Hoehler. “We dug into the EHR and discovered the authorization workflow hadn’t been updated in a few years. Even when the necessary authorization was received, it wasn’t being appropriately associated with the claim in the system, so payers were consistently denying those claims.”
The team also found an opportunity to proactively validate and document medical necessity for scheduled treatments like hyperbaric oxygen therapy to avoid repeated denials.
Ensemble didn’t just deliver data; they showed us how to truly leverage it. Their guidance went beyond the numbers, and their hands-on approach made them a true partner in our success.
Working closely with hospital staff, Hoehler’s team defined and implemented a robust solution that helped reduce first-pass denials by 84% in six months. Key initiatives included:
- Optimizing EHR workflows to effectively process authorization requests and approvals
- Standardizing medical necessity screening for scheduled services to validate and document medical necessity based on diagnosis
- Regular communication and training to help leaders and staff understand denial reports, adopt new processes and adapt to workflow enhancements
“We started looking into other areas where we could help with denial intervention, like radiology and other specialty departments,” said Hoehler. “We helped other facilities understand how denial prevention can impact patient care, and more teams became receptive to implementing those best practices.”
Over 12 months, Ensemble worked with various departments to redesign workflows, optimize existing technology and train staff on tools and techniques to prevent denials, leading to an impressive 4.2% reduction in denials across the enterprise.
Results
denials in the first 6 months
denials within 12 months
doubling wound care treatment capacity