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Maximizing Efficiency and Cost Savings in Revenue Cycle Management with Advanced Claim Editing

Piedmont HealthCare streamlined claim processing and denial management with Availity’s Advanced Claims Editing (ACE).

About Piedmont HealthCare

Piedmont HealthCare is one of the largest physician-owned multi-specialty groups in North Carolina and the Southeast, with more than 70 locations and over 200+ providers across multiple specialties. 

Challenge

Piedmont HealthCare faced significant challenges with their revenue cycle management (RCM), particularly due to the difficulty in recruiting experienced staff to manage the complexity of claim processing and frequent denials. As an independent, physician-owned multi-specialty practice, with no large health system backing, every dollar counts, and effective claim management is vital to their financial well-being. 

Piedmont HealthCare turned to Availity® to leverage the ACE feature of Availity’s end-to-end RCM platform— Availity Essentials Pro™. Piedmont HealthCare’s primary goals were to streamline the creation and management of custom edits and rules and lower the time and costs related to managing denials. Additionally, Piedmont HealthCare sought to boost their overall RCM performance and deliver timely payment for their providers.

Solution

Availity Essential Pro’s ACE equipped Piedmont HealthCare with a user-friendly interface for managing and creating custom edits without needing specialized technical skills. The system’s customizable plain language error messages simplified issue resolution for providers. Furthermore, providers could access regularly updated editing packages such as Local Coverage Determinations, National Coverage Determinations, and Correct Coding Initiative to keep pace with claim trends.

As a long-time Availity customer, Piedmont HealthCare has significantly benefited from ACE, which helps providers stay ahead of payer trends without additional IT investments. The strength of this tool lies in its ability to adapt to a constantly changing environment, helping Piedmont HealthCare remain agile and efficient. By leveraging ACE, Piedmont HealthCare saw a substantial reduction in claim denials and rework, improved accuracy in claim submissions, and enhanced financial outcomes. Additionally, they effectively kept up with claim trends and regulatory updates, ensuring continuous improvements in their revenue cycle processes.

Results

Maximizing Cost Savings through Automation:

  • Custom Edits Savings: In 2023, applying 704 custom edits to 14,245 claims saved an estimated $89,031.25. Custom edits cost $8 per claim, compared to $25 for handling a denial.1 This approach prevented issues from escalating into more costly denials, demonstrating the financial benefits of proactive error prevention. 
  • Automated Rule Changes Savings: Automating 21 rule changes impacted 52,830 claims and resulted in approximately $33,187.50 in labor cost savings. This was based on a 15-minute average per claim at a labor rate of $25 per hour.2 This automation highlighted the efficiency of streamlining processes and reducing manual intervention.

Time Savings from Advanced Custom Edits:

  • Estimated Time Savings: Applying 704 custom edits saved an estimated 10,667 hours. Handling a simple denial takes two to eight minutes, while a complicated denial can take up to an hour due to payer hold times.3 By addressing issues before they became denials, the process prevented a median of 45 minutes of additional work per claim.

Availity Essentials Pro’s ACE feature has transformed our revenue cycle management. The ability to create and manage custom edits easily has significantly reduced our claim denials and improved our financial outcomes.

Darlene McLain | Director of Business Services at Piedmont HealthCare (PHC)

What I appreciate most are the plain language error messages. They’ve made us more confident in our claim submissions and better prepared for regulatory changes. This clarity has also empowered our team to address issues proactively, saving us time and resources.

Kara Steadman | Manager of Business Services at Piedmont HealthCare (PHC)

  1. Graham, Tina. “You Might Be Losing Thousands of Dollars per Month in ‘unclean’ Claims.” Medical Group Management Association, MGMA, 1 Feb. 2014, www.mgma.com/articles/you-might-be-losing-thousands-of-dollars-per-month-in-unclean-claims.
  2. StaffPoland, Leigh, and Srivalli Harihara. “Claims Denials: A Step-by-Step Approach to Resolution.” Journal of AHIMA, Journal of AHIMA, 25 Apr. 2022, journal.ahima.org/page/claims-denials-a-step-by-step-approach-to-resolution.
  3. “More than Half of Practices Report Credentialing-Related Denials on the Rise in 2021.” Medical Group Management Association, MGMA, 26 Aug. 2021, www.mgma.com/mgma-stats/more-than-half-of-practices-report-credentialing-related-denials-on-the-rise-in-2021.

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