The Challenge
A health system using Facilitator™ for patient eligibility wanted to add another service line and manage all service lines on a single platform. Their key goals were:
- Let team members move between service lines seamlessly (shared queues, consistent UI, work-specific permissions).
- Leverage existing solutions and prior integrations—no rip-and-replace.
- Improve visibility and control across claims status, denials, and reimbursement—earlier than the 835.
The Solution
Working with the client’s SMEs, we extended Facilitator™ to automate claim monitoring and trigger actions the moment a response indicated risk—well before the final 835 arrived.
What We Deployed
- Real-Time Claim Status Monitoring: Proactive, continuous tracking to detect delays, bottlenecks, or discrepancies before they impact cash flow.
- Denial Management & Appeals: Root-cause analysis (coding, documentation, eligibility), auto-assembly of corrections, and payer-specific resubmissions/appeals within deadline windows.
- Payer Follow-Up & Coordination: Orchestrated outreach (phone, portals, letters) with automated documentation requests and status updates—logged to the case for auditability.
- Reporting & Performance Insights: AR aging, denial trends, and KPIs (e.g., Days in AR) surfaced in role-based dashboards to target process improvements.
- Payment Posting & Reconciliation: Accurate posting and matching to claims; exceptions flagged for rapid resolution to keep receivables clean.
How It Fit the Existing Stack
- Kept prior integrations (EMR/clearinghouse/payment) intact; added lightweight adapters where needed.
- Standardized queues, permissions, and workflows across service lines so staff could flex coverage without retraining.
- Centralized audit trails for every action (monitor, outreach, resubmission, post).
Impact / Results
Operational Wins
- Earlier intervention on at-risk claims—actionable triggers before 835
- Fewer manual touchpoints: staff focused on exceptions, not status hunting
- Cross-trained workforce able to float between service lines in one UI
Financial & Performance Outcomes
- Reduced Days in AR and aged-AR backlog
- Higher first-pass resolution and denial overturn rates
- Cleaner cash application with faster exception closure
Visibility & Control
- End-to-end transparency from claim submission → status → denial → appeal → payment
- Leadership dashboards to spot trends and direct daily priorities