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Production results, by category

Case studies

Proven production performance across Insurance Discovery and Claim Status workflows. Every case study outlines the client profile, specialty focus, and transaction scale so you can assess applicability to your organization. To protect client confidentiality, proprietary organization names have been anonymized.

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Featured study: a genetic testing firm

Active coverage went from 28% to 50% in four months

All Payer Insurance Discovery found the coverage. Funding type showed who pays the claim. Situs (the contract state) showed where the policy has jurisdiction. Together they cut appeals labor by 10%, with projections to cut appeals labor by 20% by end of year.

The problem

Only 28% of accounts came back with active coverage. On appeals the team also had to work out two things case by case: who pays and where. That meant whether the plan was self-funded or fully insured, and which state held the contract.

What we did

Ran insurance discovery to locate active coverage.

Classified every plan as self-funded or fully insured to show who is financially responsible for the claim: the employer or the insurance company.

Identified the situs to show where each policy has jurisdiction.

What changed

Active coverage rate climbed from 28% to 50% over four months.

Labor on appeals fell by 10%, with projections of 20% by end of year.

Self-funded plans appeal to the plan administrator under ERISA. Fully insured plans appeal to the insurer under state law. We tell you which.

Client
Genetic testing firm
Products
All Payer Insurance Discovery, funding type
Timeframe
Four months
Active coverage rateshare of accounts
10%
less labor spent on appeals

Before Integrex Health, and four months later.

Who is financially responsible?

Funding type answers it. On a self-funded plan, the employer's plan pays the claim and a TPA or carrier administers it under federal ERISA rules. That administrator is where your appeals go. On a fully insured plan, the insurance carrier pays the claim and handles the appeal under the governing state's insurance law.

Where

Situs (the contract state) answers it. It is the state where the policy has jurisdiction, and it sends the appeal down the right path from the start.

Four more engagements

Filter by product, then open a study for the problem, what we did and what changed.

  • 3 to 4Xreturn on every dollar spent over three or more years
    Insurance discovery

    A radiology practice management firm cut its self-pay population by 25% and returned 3 to 4X on every dollar spent

    Insurance discoveryRadiology and imaging

    The problem

    The client did not have an insurance discovery program in place and was handling revenue cycle operations for self-pay patients inefficiently.

    What we did

    Used All Payer Insurance Discovery, including locating active coverage across all 61 state Blue plans plus the Federal Employee Program.

    Added all eight Kaiser Permanente regions.

    Created a custom export file of active coverage results to speed up claim submission in Imagine.

    What changed

    Self-pay patient population reduced by 25%.

    3 to 4X return on every dollar spent over three or more years.

    Accelerated claim submission and payments.

    Client
    Radiology practice management firm
    Product
    All Payer Insurance Discovery
    Timeframe
    Three or more years
    Read about All Payer Insurance Discovery
  • $10Min revenue in the first month
    Insurance discovery

    A five-state RCM firm found $10M in revenue in month one and settled at $1.5M a month from month four

    Insurance discoveryHospitals and clinics

    The problem

    No insurance discovery program was in place when the engagement started.

    Outreach to patients by mail and phone to get insurance information was expensive, and patients called in to understand bills that insurance should have covered.

    What we did

    Ran All Payer Insurance Discovery across the self-pay accounts, starting with the existing backlog and continuing with new accounts each month.

    What changed

    $10M in revenue in month one, $6M in month two and $3M in month three as the backlog cleared.

    $1.5M a month from month four onward.

    Far less outbound mail and phone outreach, and fewer incoming calls from patients about their bills.

    Client
    RCM firm working on behalf of a midwestern provider in 5 states
    Product
    All Payer Insurance Discovery
    Timeframe
    Three years and continuing
    Read about All Payer Insurance Discovery
  • +25%successful claim status responses
    Claim status

    Claim status success rose 25% for an RCM firm serving a 1,000+ bed health system

    Claim statusHealth system

    The problem

    Too many phone calls and web lookups were needed to get claim status. Patient information, including member IDs, was often wrong.

    The goal was touchless transactions that lower labor cost.

    What we did

    Delivered Claim Status and Resolution with extended adjudication detail for major national payers and a multi-state Blue plan.

    Used automated data correction to fix patient information before it caused failed responses.

    Placed accounts with certain statuses into a future work queue with a trigger response.

    What changed

    25% more successful claim status responses.

    Allowed amount, patient responsibility and actionable denial descriptions now come back in the response and set up touchless transactions.

    Labor shifts from routine touches to high value claim denials.

    Client
    RCM firm working for a southeast health system with 1,000+ beds
    Product
    Claim Status and Resolution, with extended adjudication detail
    Read about Claim Status and Resolution
  • 90%of claim status calls avoided
    Claim status

    An RCM firm serving a radiology and imaging group avoided 90% of its claim status calls by receiving a successful claim status response on 7,204 of 7,500 claims (96%)

    Claim statusRadiology and imaging

    The problem

    Data integrity issues in the provider inventory file blocked full automation. Without current claim status the team allocated accounts inefficiently.

    A contingency relationship with the client left no room for wasted effort.

    What we did

    Used AI Pattern Analyzer to correct patient and claim information before submitting the claim status request.

    Called the Anthem Prefix Finder API to see whether a member belonged to an out of state Anthem state plan.

    Added claim adjudication detail that explained the missing documentation behind a denial.

    What changed

    7,204 of 7,500 requests returned successful responses.

    90% call avoidance.

    Strong denial team performance led to added engagements for resources and technology services.

    Client
    RCM firm serving a radiology and imaging group
    Product
    Claim Status and Resolution
    Requests
    7,204 of 7,500 returned
    Read about Claim Status and Resolution

Results reflect individual client engagements and will vary by payer mix and data quality.

Published writing

Papers by Ken Poray

Published by Health Data Management. Each opens on the publisher's site.

Find out what your accounts would show.

Talk with the Integrex Health team about coverage discovery and claim status for your workflow.

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