Client Snapshot
Organization Type
Privately owned specialty hospital focused on substance detox and behavioral health.
Scope of Services
• Inpatient substance detox
• RCM, Admissions and Utilization Management operations leadership
• Cross-functional integration of RCM, UM, and clinical teams to ensure compliance and financial coverage throughout the patient stay
• Audit management and process improvement to reduce payer take-backs
• Referral process streamlining to accept more complex insurance patients and maintain high census
Engagement Type
Operational and revenue cycle management turnaround with strategic advisory for joint venture expansion.
Location
Northeastern United States
The Challenge
The hospital operator was experiencing significant cash flow issues due to underperforming revenue cycle management (RCM) and utilization management (UM) departments. Despite providing high-value substance detox services, they struggled with:
• Inconsistent and incorrect billing submissions to Medicare and commercial payers, resulting in cash flow delays.
• Difficulty tracking and submitting compliant claims based on payor-specific requirements.
• Inability to fully optimize DRG reimbursement due to incorrect coding and operational inefficiencies.
• A lack of alignment between clinical workflows, RCM, and UM teams, hindering accurate reimbursement and compliance.
• Leadership exploring the possibility of launching a standalone billing company for internal and external clients, but the current operations were not yet stable enough to support this.
Our Role: Hands-On Leadership in Revenue Cycle and Utilization Management
Kaizenleap’s engagement was built on a deep integration with RCM, Admissions and Utilization Management departments. We provided both tactical execution and strategic advisory, ensuring all departments worked together seamlessly from patient referral through to billing submission. This allowed for full compliance and financial coverage throughout the patient’s stay.
Key Areas of Focus:
• Admissions: Led the overhaul of the admissions and referral process to ensure quicker patient acceptance, including those with complex insurance plans, and kept census near 100%.
• Utilization Management: Directed UM to ensure compliance with insurance plan requirements, leading to a successful audit result with zero take-backs.
• Cross-Department Integration: Aligned the RCM, UM, and clinical teams to ensure all aspects of the patient journey were covered financially and compliantly, from initial referral to claims submission.
• Audit and Process Improvement: Managed payer audits and implemented new processes to ensure ongoing compliance, including passing a major payer audit that had previously targeted a significant amount of reimbursement for take-back.
What We Delivered
| Deliverable | Impact |
|---|---|
| RCM and UM Department Leadership | Led RCM, Admissions and Utilization Management departments, ensuring they operated seamlessly together for improved cash flow and compliance. |
| Revenue Cycle Optimization | Streamlined the billing process, ensuring accurate and timely claims submission to all payers, resulting in improved cash flow. |
| Utilization Management Audit Success | Mitigated a payer audit that targeted $800K in take-backs, passing the audit after implementing new compliance processes. |
| Referral Process Streamlining | Reduced wait times for patient admissions and increased access to patients with complex insurance, maintaining a high census. |
| Cross-Functional Integration | Built collaborative workflows between billing, utilization review, and clinical teams to improve overall financial performance and compliance. |
Results
• Increased Cash Flow: Improved claims submission processes, leading to higher cash flow and reduced billing errors.
• Zero Payer Take-Backs: Successfully navigated a major payer audit, preventing $800K in potential take-backs and putting the hospital in a strong position for future reimbursements.
• High Compliance Standards: Implemented process improvements that led to compliance with payer requirements, reducing denials and maximizing reimbursement.
• Sustained High Census: Optimized the referral process to accept patients with more complex insurance, maintaining a near 100% census and ensuring full occupancy.
• Positioned for Growth: Helped the leadership team lay the groundwork for launching a new billing company once core operations were stabilized.
Why It Worked
Kaizenleap’s success came from integrating into the day-to-day operations of the RCM and UM departments, making sure both teams worked closely together to optimize reimbursement and maintain compliance. Rather than focusing only on the back-end claims, we aligned clinical practices with financial goals, ensuring each step of the process—from patient admission to billing submission—was fully optimized. Our hands-on approach led to sustained operational improvements, increased revenue, and a pathway to future growth.
Services Provided
• RCM, Admissions and Utilization Management leadership and integration
• Revenue cycle optimization and compliance improvement
• Utilization review process improvements
• Audit management and payer relations
• Referral process redesign to streamline patient acceptance
• Strategic advisory for launching a new billing company