Case Study: Revenue-Cycle Management and Artificial Intelligence

Inadequate Pre-Certification Resources Negatively Impact Reimbursements

Located in a large metropolitan city in the Southeast, this clinic is part of a larger comprehensive healthcare network. The clinic employs more than 2,200 outpatient clinical providers who schedule procedures that potentially require payer pre-certification of services―thus, necessitating a review of payer portals and the submission of pre-certification requests. The clinic’s pre-certification department was not adequately staffed with enough resources to address each request efficiently, resulting in a high volume of high-dollar denials and write-offs as well as a reduction in reimbursements from missing pre-certifications.