Recovered 87% of $1M unpaid AR for an orthopedic surgical group, boosting cash flow and refining billing processes, especially in managing capitated plans using Aprima. Table of Contents About the Client Initial Engagement and Challenges Solution Strategy Results Conclusion About the Client OrthoWest is a leading orthopedic surgical group that is under the umbrella of SCA OptumHealth. The group specializes in providing advanced orthopedic care, including surgical procedures, rehabilitation services, and comprehensive patient management. Over the years, OrthoWest has built a strong reputation for delivering top-tier medical services to patients across the region. However, despite their clinical success, they faced significant challenges in managing their accounts receivable (AR), particularly with a large amount of unpaid claims that had accumulated over the past year. Initial Engagement and Challenges The engagement began when Orthowest, reached out regarding a substantial amount of old AR—specifically, $1 million in unpaid claims that had accumulated over the previous 12 months. They emphasized that these outstanding balances were all real and collectible, representing a significant financial burden for the group. The primary challenges identified were: High Volume of Old AR: The group had $1 million in outstanding claims that needed to be recovered. These were not new claims but rather aged receivables, which are typically harder to collect. Capitated Services: A significant portion of these accounts fell under capitated plans, where services are bundled, adding complexity to the claims recovery process. Understanding and navigating the nuances of these plans was critical. System Knowledge: The client used Aprima, a specific practice management and EHR system, which required a thorough understanding to efficiently handle the recovery process. The Director of Revenue of OrthoWest contacted us. This indicated a level of trust and expectation that we could deliver the results they needed. The initial quote provided for the collection efforts ranged between 11% and 15%, contingent on the complexity and success of the recovery. Solution Understanding the complexity and scale of the challenge, our team devised a customized solution aimed at efficiently recovering the $1 million in unpaid AR for OrthoWest. The solution involved several key components: In-Depth Analysis: We began with a detailed analysis of the unpaid AR. This included categorizing the accounts based on age, payer type, and the complexity of the bundled services under the capitated plans. Aprima System Expertise: Our team dedicated resources to mastering the Aprima system. This was crucial as it enabled us to seamlessly integrate our recovery process with the client’s existing workflows, ensuring no disruption to their ongoing operations. Capitated Plan Navigation: Given the significant number of accounts under capitated plans, we invested time in understanding the specific bundled services involved. This allowed us to accurately pursue the correct reimbursements, avoiding potential pitfalls associated with misinterpretation of these complex plans. Dedicated Recovery Team: We assigned a specialized team with experience in orthopedic billing and AR recovery to handle OrthoWest’s account. This team worked closely with the client to ensure alignment on goals and transparency throughout the process. Strategy Our strategy to recover the $1 million in unpaid AR for OrthoWest was comprehensive and multi-faceted: Segmentation and Prioritization: We segmented the unpaid AR into different categories based on the likelihood of recovery. High-value and high-probability claims were prioritized to ensure quick wins and immediate cash flow improvement. Tailored Communication: Understanding the nuances of capitated plans, our communication with payers was highly tailored. We ensured that all claims were presented with the correct coding and supporting documentation, reducing the chances of denials or delays. Persistent Follow-Up: AR recovery is often about persistence. Our team followed up rigorously with payers, ensuring that claims were not just submitted but actively pursued until payment was secured. Transparency and Reporting: Throughout the process, we maintained regular communication with our client, providing detailed reports on our progress. This transparency helped build trust and allowed for real-time adjustments to the strategy as needed. Medientsky’s implementation strategy included: Resource Allocation: Live EV Checks: 2 dedicated resources Scheduled EVs:3 full-time employees (FTEs) Multi-Channel Communication: BillingParadise facilitated RCM communications through email, phone, and Slack, ensuring seamless collaboration. Query Management: BillingParadise handled over 200 queries daily via Slack, ensuring same-day responses, an essential aspect of RCM performance. Results The results of our AR recovery efforts for OrthoWest were significant and impactful: Recovery Rate: Within the agreed-upon timeframe, we successfully recovered approximately 87% of the $1 million in unpaid AR. This was a substantial financial boost for the group, improving their cash flow and reducing the financial strain from outstanding receivables. Improved Processes: Beyond just recovering the unpaid AR, our work with OrthoWest helped identify and rectify inefficiencies in their billing processes, particularly related to handling capitated services. These improvements will help the group avoid similar AR build-ups in the future. Client Satisfaction: They expressed high satisfaction with our services. The recovery rate exceeded their expectations, and our transparent communication and reporting ensured they were always informed of the progress. They noted that the group’s financial position was considerably stronger thanks to our efforts. Conclusion The recovery of $1 million in unpaid AR for OrthoWest was a testament to the effectiveness of our tailored approach to revenue cycle management. By combining in-depth analysis, system expertise, and persistent follow-up, we were able to deliver substantial financial recovery for the client. Moreover, our work didn’t just address the immediate problem; it also set the stage for improved financial management in the future. This case study highlights the importance of specialized knowledge in both the client’s industry and their specific operational systems. For orthopedic groups or any medical practice facing similar challenges with old AR, our approach offers a proven pathway to significant financial recovery. We look forward to continuing our partnership with OrthoWest and exploring new ways to enhance their revenue cycle management processes.
