IBM > Case Studies > Revolutionizing Healthcare Claim Denials: Advent Health Partners' 500% Productivity Lift

Revolutionizing Healthcare Claim Denials: Advent Health Partners' 500% Productivity Lift

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Technology Category
  • Application Infrastructure & Middleware - Database Management & Storage
  • Platform as a Service (PaaS) - Application Development Platforms
Applicable Industries
  • Finance & Insurance
  • Healthcare & Hospitals
Use Cases
  • Time Sensitive Networking
  • Usage-Based Insurance
Services
  • Cloud Planning, Design & Implementation Services
The Challenge
Advent Health Partners, part of the Powered Health group, was facing a significant challenge due to rapid changes in healthcare regulations in the United States. The re-introduction of the Recovery Audit Contractor (RAC) program and the move to Electronic Medical Records (EMRs) had left many hospitals struggling to keep pace. This resulted in inefficiencies in the healthcare revenue cycle, with billions of dollars tied up in insurance claims denials. The situation was further complicated by the fact that hospital data, both structured and non-structured, was generally stored in siloes, with a lack of communication between different departments. Some processes were still heavily reliant on paper records. With claims-related data scattered across different locations and stored in multiple formats, it was very difficult for analysts to bring together all the information required to review a denied claim and decide whether there was a case for appealing the decision.
About The Customer
Advent Health Partners is part of the Powered Health group and is dedicated to driving maximum financial returns for healthcare providers. The company uses its CAVO technology to provide claims appeal services and coding corrections of denied claims, both as an outsourced service offering and as a standalone product. Advent was established to help healthcare and insurance providers optimize the claims appeal process, reviewing vast volumes of documents to determine the root causes of denials and identifying opportunities for process improvements.
The Solution
To address these challenges, Advent developed CAVO, a technology that integrates multiple sources of data, including paper documents, indexes them and simplifies access to disparate data related to a claim. At the heart of this revolutionary technology is IBM Cloudant, a NoSQL database platform built for unstructured data stored in the cloud. The platform’s impressive scalability makes it easy for Advent to manage growing data volumes. Advent has seamlessly integrated the Cloudant platform with the Apache Lucene indexing and search library, providing an easy-to-use search engine. This allows users to instantly develop a smart search for text for a particular claim, across all of a provider’s claims, or even across an entire health system, significantly accelerating information retrieval. The solution also complies with the Health Insurance Portability and Accountability Act (HIPAA), which sets the standard for protecting patient data.
Operational Impact
  • The implementation of CAVO has transformed the way appeals, documents, and information is managed, generating valuable returns for its customers. It has allowed Advent to be highly competitive in the saturated denial of claims market, as it can review and process claims denial cases much faster than other service providers. The improved efficiency has also delivered impressive savings on the highly-skilled staff needed to perform such work. As teams can work through a higher volume of cases, Advent has been able to maintain relatively flat staffing levels, even as its business has grown. The time saved on low-level work empowers these clinical workers to focus on more value-added tasks. Furthermore, Advent’s new approach is delivering a massive financial impact for clients too. As CAVO makes it less expensive and time-consuming for hospitals to appeal claims, they are more likely to recoup valuable dollars from appeals.
Quantitative Benefit
  • Up to 500% faster claims review
  • Millions of dollars returned to hospitals for services provided
  • Improved efficiency of analysts so they can review more claims annually

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