Case Study
Situation
- Regional Mental Health provider organization serving at-risk Women and Family’s recently experiencing decline in payer rates and overall revenue capture putting annual operating budget at risk
- Need for Executive and Administrative leadership to provide more guidance to Board of Directors regarding revenue cycle performance vs. industry and market comparison sets
- Limited internal expertise to review and analyze existing billing system reporting and supporting processes to identify potential opportunities to maximize revenue capture and collections from private payers
SMA Services
Operations Review
Business Planning
Business Optimization
Actions & Impact
- Analyzed current payer contracts for CPT code level billing and payment experience vs. local and national market-based comparative sets
- Benchmarked each payer contract vs. other internal payer contract experience
- Analyzed current CPT code utilization vs. other internal payer contract experience and SMA Behavioral Health industry experience
- Identified and quantified opportunity to renegotiate current payer rates to align with CMS and Medicaid fee schedules
- Identified improvement opportunities in revenue capture for In-Network vs. Out-Of-Network practices
- Identified and quantified variations in individual and group practice billing patterns