Operational Efficiency & Denial Management

Use Cases addressing reduction of operational bottlenecks, improving denial management processes, and transitioning to data driven resource allocation.

Preventing Denials from Provider–Facility Mismatches

A Federally Qualified Health Center faced recurring denials because providers were selecting the wrong facility type when submitting claims. Their practice management system produced noisy data due to non billable student providers, making it difficult to identify errors. Leadership lacked visibility into which staff members were driving the issues.

  • RevOps enabled the team to filter out non billable visits, isolate billing providers, and reveal mismatches between provider specialty and facility type. Leadership identified staff training gaps, corrected claims before submission, and implemented ongoing monitoring with automated watchers to prevent repeat errors.

    • Reduced preventable denials by identifying mismatched provider facility pairings early

    • Improved staff accuracy and accountability with clearer workflows and targeted training

    • Strengthened financial stability through proactive monitoring and fewer rejected claims

Achieving CARC Accountability and Operational Excellence

A multisite urgent care network wanted to understand which departments or users were responsible for specific CARC denial codes. Their homegrown accountability system lacked flexibility, making it impossible to break down denial trends by provider, business line, or billing partner. Leadership could not target improvements effectively.

  • RevOps integrated the network’s CARC mappings into an interactive analytics framework, enabling segmentation by responsibility group, location, and user. The platform tied each denial to its financial impact and revealed patterns requiring training or workflow adjustments across internal teams and external billing vendors.

    • Increased accountability by assigning each denial reason to a clear owner

    • Improved performance across billing partners with transparent, data driven comparisons

    • Uncovered training needs and workflow gaps that strengthened operational efficiency

Driving Better Coding Practices Through Unspecified Diagnosis Analysis

A healthcare practice experienced reimbursement delays caused by unspecified diagnoses. Claims with “Z coded” diagnoses took significantly longer to pay, but clinicians were unaware of the financial impact. Leadership needed clear data to show how vague coding affected cash flow and justify targeted process improvements.

  • RevOps segmented claims by diagnosis specificity, compared payment timing across categories, and revealed where coding delays originated. Leadership used these insights to train clinicians, target departments with the greatest delays, and monitor improvements over time to reinforce accurate documentation and coding.

    • Reduced payment delays by improving diagnosis specificity at the point of service

    • Strengthened clinician engagement through clear data showing financial impact

    • Built a sustainable framework for ongoing monitoring and coding accuracy

Enhancing Appeal Letter Processes with RevOps

A national health system observed that newer billers frequently wrote off denied claims instead of preparing appeal letters. Gathering the necessary data for appeals was slow and burdensome, leading to unnecessary write offs, lost revenue, and negative patient experiences when balances were misassigned.

  • RevOps centralized denial data, supported standardized appeal templates, and enabled teams to export complete claim information for faster appeal preparation. The organization also began A/B testing letter formats and planned future integrations to automate appeal generation and track appeal success at scale.

    • Reduced unnecessary write offs by making appeals faster and easier to prepare

    • Improved win rates with standardized templates and evidence backed submissions

    • Increased staff confidence and capability with clearer workflows and lower administrative burden

Detecting and Preventing Billing Mismatches

An ophthalmology practice discovered that bilateral injections were often being reimbursed as single units, costing them thousands of dollars. Their practice management system marked these claims as fully paid, making the shortfalls invisible. External billers also missed the issue during audits, leaving significant revenue unrecovered.

  • RevOps compared charged versus paid amounts across injection CPT codes and uncovered 51 affected claims over twelve months. The practice resubmitted claims, implemented a custom mismatch tag, and set up automated watchers to flag new discrepancies in real time. Billing partners gained clearer visibility into recurring issues.

    • Recovered missing reimbursement for high value bilateral procedures

    • Prevented future losses by tagging and monitoring quantity mismatches automatically

    • Improved billing partner accountability through transparent, shared insights

Optimizing Claim Submissions with Real-Time Testing

A behavioral health organization suspected that out of network travel exceptions coded as “elective” were being denied unnecessarily. They believed coding certain claims as “emergent” better reflected patient circumstances but lacked data to validate the hypothesis. They needed a way to test this strategy without disrupting daily operations.

  • Using RevOps, the team ran a four month controlled trial comparing reimbursement outcomes for “elective” versus “emergent” claims. The platform tracked results in real time, segmented claims by code type, and delivered automated reports to measure financial performance without adding manual work.

    • Collected an additional $100,000 by coding qualified claims as “emergent”

    • Reduced denial rates significantly compared with “elective” coding

    • Standardized a more effective claim submission strategy across the organization

Optimizing Provider Schedules and Mobile Services

A community health center struggled with clinician lateness due to multi site scheduling conflicts and lacked visibility into patient volume for its mobile dental van. Their practice management system could not break down encounters by location or reveal workload issues, creating inefficiencies that frustrated patients and reduced service capacity.

  • RevOps quantified how often providers were scheduled across multiple sites per day, helping leadership redesign schedules with appropriate travel buffers. For mobile services, RevOps mapped visits by ZIP code to identify high demand areas and optimize routing for the dental van, ensuring resources reached patients more effectively.

    • Reduced late arrivals and improved patient flow with smarter provider scheduling

    • Maximized mobile unit impact by aligning routes with actual patient demand

    • Increased operational efficiency by turning claims data into actionable planning insights

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