The Challenge
A multi-site health system centralized insurance discovery and verification in its CBO, but lacked a workflow engine to manage the volume across locations. Teams needed a way to:
- Process verification results, validate coverage, and post updates to the legacy billing system
- Prioritize deficiencies (missing/invalid coverage, coordination of benefits, eligibility conflicts)
- Auto-route exceptions to the right teammates/supervisors with clear ownership and SLAs
- Hand off qualified cases to Financial Assistance for discounts or payment arrangements—without swivel-chairing between systems
The result was inconsistent follow-through, manual status hunting, and limited visibility across the centralized operation.
The Solution
We deployed Facilitator™ to standardize and orchestrate the end-to-end CBO workflow.
- Automated Intake & Validation: Ingests discovery/verification outputs, validates coverage rules, flags discrepancies (plan mismatch, term dates, service non-covered), and normalizes data for posting.
- System Posting to Legacy Billing: Clean results are posted directly to the billing system; exceptions spin off as work items with full context.
- Priority Queues & Smart Routing: Risk- and due-date-based prioritization assigns accounts to individuals or pooled teams; escalations go to supervisors with SLA timers.
- Guided Follow-Up: Built-in reason codes and next-best-action prompts streamline outreach to patients, payers, or Financial Assistance (for discount calculation or payment plans).
- Control & Compliance: Role-based access, audit trails, and operational dashboards provide real-time visibility (work in queue, aging, completion rates).
Impact / Results
Operational Consistency
- One standardized process across all sites; fewer hand-offs and rework
- Exceptions surfaced instantly; routine cases auto-posted without manual touches
Speed & Throughput
- Faster clearance of clean verifications; prioritized attention on high-impact deficiencies
- Less swivel-chairing between systems; fewer status checks
Financial Confidence
- More accurate coverage on file → fewer day-of-service surprises and downstream denials
- Seamless handoff to Financial Assistance for discounts/payment plans improves patient pay capture
Visibility & Accountability
- Real-time dashboards for leaders: queue health, SLA risk, top denial/deficiency drivers
- Complete audit history of every action from verification to billing post