/ PREPAY REVIEWS / ITEMIZED BILL REVIEWS /
Regional Health Plan Decreases Pre-Pay Hospital Bill Review Time by 500+% Per Case
This regional health plan has an internal team of RNs performing hospital bill pre-pay reviews.
Nurse reviewers previously either:
- requested the itemized bill (IB) directly from the provider based on rules, edits and/or outliers.
- accessed/exported the IB directly from the EMR.
Once they obtained the IB image, RNs validated charges line-by-line based on the payer policy with that provider. Once they found a line item that they were unable to validate, they manually keyed it within their workflow, assigned a denial reason, and reported/shared the case’s rejections with the provider. In short, IB reviews were a time-intensive process due to the variety of formats and overall document length.
This regional health plan is leveraging CAVO®’s IB Reviews module to transform imaged IBs into filterable and sortable data. After an initial demo with Advent, this payer evaluated building an internal solution, but after an intense R&D process decided to leverage best-in-breed CAVO technology.
The plan initially provided Advent with approximately 20 different IB formats. Our development team trained CAVO to recognize these specific formats, enabling instant capture of the IB data. Their nurse review team replaced the manual line-by-line review process with a targeted approach based on filterable, sortable IB data. Additionally, after evaluating their particular review process, this plan elected to bypass the CAVO user interface; instead, they are leveraging CAVO’s open API to import the captured IB data directly into their internal workflow—ensuring their team completes reviews within a single platform.
Implementing CAVO’s IB Reviews module decreased overall review time per case 500+% – while also significantly positively impacting the high dollar review threshold, all without additional FTEs or disrupting the internal workflow process. After comparing building (and maintaining) or purchasing our targeted solution, the highest ROI with the least investment of internal resources was clearly CAVO for both short- and long-term opportunities.