200-Bed Community Hospital

The Challenge

This 200-bed community hospital serves a mixed payer population — 42% Medicare, 28% commercial, 18% Medicaid, and 12% self-pay. Like many mid-sized community hospitals, it had been managing its revenue cycle internally with a team of 34 billing and coding staff. The operation was functional but far from optimized.

An external consultant's preliminary assessment flagged potential revenue leakage exceeding $3M annually. The hospital's board authorized a search for an RCM partner that could stop the bleeding without disrupting clinical operations.

• Revenue leakage across multiple vectors — charge capture gaps, CDI shortfalls, undercoded DRGs, and missed secondary payer billing were draining revenue from every department
• Clinical Documentation Improvement (CDI) gaps — physician documentation did not consistently support the severity of illness and risk of mortality, leading to DRG downcodes on an estimated 15% of inpatient cases
• High cost to collect — at 5.8 cents per dollar collected, the hospital's collection cost was 45% above the HFMA benchmark
• 94% clean claim rate — while seemingly respectable, the 6% rework rate on a $120M annual charge volume represented enormous waste
• Aged AR growing — the 90+ day AR bucket had grown 28% year-over-year, with $4.2M sitting in aging status

The Solution

Comprehensive Revenue Integrity Assessment

Revenue Synergy began with a 30-day deep-dive into every revenue-producing department. We analyzed charge capture rates by department, coded DRG distributions against expected case-mix index, secondary payer identification rates, and denial patterns by payer and denial reason. The assessment identified $3.4M in addressable revenue improvement opportunities.

CDI Program Implementation

We deployed a concurrent CDI program with certified clinical documentation specialists reviewing active inpatient charts. Working alongside hospitalists and specialists, the CDI team identified documentation clarification opportunities in real-time — before the patient was discharged and the coding window closed. The program focused on sepsis documentation, malnutrition screening, respiratory failure specificity, and heart failure staging.

End-to-End Coding and Billing Optimization

Our hospital coding team replaced the internal coding operation, bringing CCS and CCS-P certified coders who specialize in facility coding. The team implemented a 48-hour coding turnaround for all discharges, concurrent outpatient coding for high-volume departments, and automated charge reconciliation for surgical, radiology, and laboratory services.

Aged AR Recovery Program

A dedicated task force attacked the $4.2M in 90+ day aged AR. Using payer-specific appeal strategies, missing information follow-up, and coordination of benefits resolution, the team recovered $1.3M from accounts the hospital had effectively abandoned.

Implementation Timeline

The Results

• $2.1M recovered in Year 1 — through CDI improvements ($1.4M), aged AR recovery ($1.3M), charge capture corrections ($420K), and reduced denials, offset by partnership costs
• Cost to collect: reduced 40% — from 5.8 cents to 3.5 cents per dollar, well below the HFMA benchmark
• Clean claim rate: 94% to 99% — reducing rework volume by 83% and accelerating cash flow
• Case-mix index: +0.12 points — reflecting more accurate documentation and coding of patient acuity, not upcoding
• 90+ day AR: reduced 62% — from $4.2M to $1.6M through systematic recovery and prevention
• Staff optimization: 34 to 22 billing FTEs — with 8 staff redeployed to patient access and financial counseling roles

The hospital's board approved a Year 2 expansion of the partnership to include physician practice billing and emergency department coding optimization, projecting an additional $800K in annual improvement.