RCM Success: A Three-Part Case Study

Very few things about medical billing are straightforward, but it’s especially true in pediatrics. Proper coding, modifiers, and changes in Medicaid rules and payer guidelines can turn a simple office visit into a minefield of dependencies. Staffing shortages have also created their own set of challenges. It’s hard enough finding a biller with experience, let alone one with pediatric experience.

Good billing practices are the lifeline to financial viability of a pediatric practice. Outsourcing your billing can have a profound impact on your bottom line, but you must choose a partner who understands pediatric billing and all of the nuances that come with it. The following customer stories demonstrate how OP RCM works to increase cash flow, decrease days in A/R, and fill in those unexpected staffing gaps to help practices stay financially healthy.

Results with OP RCM™

  • 14% increase in payments
  • 4% increase in charges
  • 22% reduction in average days in A/R 

Results with OP RCM™

  • 220% increase in overall vaccine payments
  • 113% increase in charges
  • 151% increase in total payments

Results with OP RCM™

  • 31% reduction in average days in A/R
  • 21% increase in total payments even after practice charges went down 7% during the height of the COVID pandemic

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1. A Cure for Staffing Challenges Leads to a 14% Increase in Payments

For one mid-sized practice in Teton County, Wyoming, 2022 was a year full of change. After one of their billers left unexpectedly, they found that the recruitment landscape had shifted dramatically since they last needed to hire staff. The cost of living in their area had been trending upward and the idea of dedicating time and resources toward recruitment without the guarantee of finding even one good biller was a very real concern.

The practice has used OP’s pediatric-specific EHR since 2012, so when it came time to find a new outsourced billing solution, they decided to explore a partnership with OP RCM. As they suspected, the RCM team was as exceptional as the EHR.

After a successful transition to OP RCM, the practice started seeing the efficiencies that come with economies of scale, which is reflected in the numbers. Charges increased by 4% and payments increased by 14%. Better billing practices also allowed OP RCM to get more money out of each claim, and those claims are getting paid faster. The average days in A/R was reduced by 22%.

2. Reaching Clinical and Financial Goals in Broward County, Florida

In late 2019, life at one pediatric practice in Broward County, Florida changed abruptly. A neighboring practice closed its doors and sent most of its patients their way. Suddenly it felt like there weren’t enough hours in the day to meet the demands for quality patient care, let alone tend to the day-to-day needs of the practice.

Prior to the influx of new patients, the practice had set an objective of increasing the number of patients who got up-to-date and stayed up-to-date with their vaccines. Now with even more patients to care for, the office manager quickly realized that in order to tackle this lofty goal, she needed to seek outside help and turned to OP to help solve some of these problems. OP’s recommendations were twofold:

1. On the clinical end, the practice began using OP’s recall and messaging functionality to identify and schedule patients overdue for immunizations.
2. To manage the financial side of the business, the practice began working with OP RCM to ensure their claims were processed faster and more efficiently, and were being paid at a higher rate.

The practice’s vaccine policies were incredibly easy to implement. OP provides a summary of each patient’s immunization history and required vaccinations directly in the patient chart. Detailed reports of immunization histories can also be created to prompt for upcoming vaccinations, calculate the provision of multiple vaccines, and issue alerts for overdue vaccines. On the financial side, the OP RCM team ensured that vaccine claims were paid quickly and advised the practice when their fee schedules needed to be refreshed.

The results that OP RCM delivered were pivotal for the growth of the practice overall, and specifically, served to demonstrate the success of their vaccination efforts. In the two years since they started working with OP RCM, the practice has seen an incredible 220% increase in their overall vaccine payments. Their cash flow has also exploded, with charges increasing 113% and total payments increasing 151%.

3. Lending a Hand During an Emergency in South Carolina

Healthcare as an industry has been hit hard with unexpected staffing shortages since the start of the pandemic, leaving a profound negative impact on the finances of many pediatric practices. A four-provider group in Beaufort County, South Carolina, experienced this exact situation towards the end of 2020. A trusted biller unexpectedly contracted Covid, but everyone at the practice anticipated he would eventually return. Over the span of several months, the practice had submitted almost no claims, and then came the devastating news: their biller had passed away.

What followed was a period of intense confusion and mourning among the entire staff. Without an immediate solution, the owner of the practice called OP RCM and began outsourcing their billing that same month. What wasn’t immediately obvious to the practice at the time was the trickle-down effect that comes with having a singular billing expert within a healthcare organization.

When the practice first signed on with OP RCM, there was a lot of cleanup needed related to patient eligibility. The front desk had been checking-in patients without asking for insurance cards, leading the system to flag them as self-pay. This led to patient statements being generated in error, confusion among parents, and frustrated staff trying to identify what went wrong as they dealt with a barrage of phone calls from families trying to understand why they were being billed for office visits that normally would have been covered by their insurance.

After a steep learning curve, the practice took the lessons taught by the OP RCM team and started to see some real improvements, such as average days in A/R being reduced by 31%. One of the more surprising results, however, spoke to the efficiencies brought by the experienced team of OP RCM billers. While the practice’s overall charges decreased by 7% during the height of the COVID pandemic, total payments increased by 21%.

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