$42 Million
Net Revenue Impact
1,200 + Beds
Multi-Hospital & Health System
Bankruptcy Risk
Pricing and Chargemaster Fixes
Grupo HIMA – San Pablo is one of the largest hospital and healthcare systems in Puerto Rico. In light of bankruptcy risk due to financial deterioration and staff turnover, they were in urgent need of a comprehensive revenue integrity review and tactical improvement implementation plan. MedCom conducted a phased approach to first assess the situation and then lay out the most effective implementation plan for successful execution and sustainable revenue and operational improvements. Key components of the revenue assessment included reviewing:
- Charge capture to prevent revenue leakage
- Chargemaster coding and mapping
- Charge line volume compared to market and industry averages
- HIMA pricing against Market pricing
- Cost to Charge Ratios
- Contract rates and fee schedules compared to 835 payment files
- 835 payment and denial patterns
Outcomes and Improvements
- Revenue Improvement: Onsite Audit ($ 5 million)
- Emergency Room Visit Level correction ($2 million)
- Observation charge improvement opportunity ($3-4 million)
- Hospital ChargeMaster Improvement ($27 million)
- Coding Correction, Price Increase, and Payor Rate Table updates ($3 million)
- Hospital 835 Payment and Denial Findings ($24 million)
- Department Charge Process Improvement ($3 million)
- Operating Room Charge Restructure ($3 million)
- Red Medica Physician Practice ChargeMaster & Charge Capture Improvement ($4 million)
- Up to date and accurate chargemaster for both hospitals and physician practice resulting in increased operating efficiency and reduced denials.
Sustaining Improvements
MedCom acknowledges that a successful program must be monitored and cultivated to continue to thrive. Our organization provides ongoing support that extends past the conclusion of any engagement to ensure an effective program and exponential growth in the years that follow.
- MedCom manages ongoing improvement through a trio of revenue cycle solutions, which includes MedCom's proprietary SaaS solutions and team involvement:
- CDM Improvement Team comprised of HIMA management and MedCom subject matter experts
- CMNavigator® SaaS, for chargemaster management, and
- RANavigator® SaaS, for monthly monitoring of 837/835 payment analytics.
