The Challenge
A major women's and children's hospital faced substantial financial risk after an audit identified millions in uncollected revenue, inconsistent pricing, and non-standardized billing practices. The hospital lacked reliable processes for verifying insurance coverage, generating estimates, securing pre-authorizations, or collecting payments at defined touchpoints.
The gaps resulted in substantial revenue leakage and operational inefficiencies that compromised financial sustainability.
The Approach
A comprehensive review of inpatient and outpatient workflows revealed inconsistencies at every stage of the billing cycle. A future-state design established standardized processes across:
- Estimate generation, pre-authorization, and payment collection.
- Coding and claim submission workflows.
- Charges standardized and updated regularly based on accurate cost data.
- Payer agreements reconciled and aligned with the hospital's new pricing structure.
- Training delivered to clinical and administrative teams on the new processes.
- Governance mechanisms introduced to monitor compliance and sustain improvements.
The Outcome
The transformation delivered approximately $25M in financial benefits, improved transparency between clinical and administrative functions, and positioned the organization for long-term financial sustainability while maintaining high-quality care. The new system reduced variability, strengthened accountability, and improved revenue integrity.