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Background and Challenges

Managing a healthcare provider system is a complex responsibility. In a hospital, you need to manage medical services, patient accommodations and many other complementary services that fulfill the organization’s offer and value chain.

The client is constantly required to coordinate with many different types of stakeholders – patients, employees, insurance companies and suppliers – that all utilize various processes and systems to accurately capture and manage patient and provider information. All the data from the various systems should be able to be analyzed and monitored automatically, providing decision makers with the most accurate and updated organizational and financial information available. However, this was not happening. The client realized that gaps within the various processes and networks were impacting business performance and, ultimately, the patient experience.

The client was struggling – buried under manual processes and relying upon costly auditing tools that were unable to actively respond to the organization’s needs for operational effectiveness. Suddenly, the increased number of healthcare units, the range of new services offered and the demands from varied patients, reinforced the need for a new approach. In other words, the increasing volume of processes, data and coding registration requirements were calling for an automated tool that could manage and monitor internal audits and processes.

The Solution

As a healthcare provider reference, the client was seeking to gain better operational control across their organization, and decided to install an auditing software tool – RAID Healthcare – in order to automate and standardize workflows, aggregate real-time data, identify inefficiencies and allow for the redesign and correction of business processes.

The client’s goal was clear: optimize and standardize operational processes across all their health units through a continuous monitoring strategy. The implementation of this new management methodology would provide the client with a real-time view and better understanding of business behavior and performance.

By taking advantage of its flexible features, our client was able to leverage RAID Healthcare software tool in order to exceed all of the challenges within each mapped process below:

Results and ROI

By gathering process and system data and running performance auditing rules, RAID Healthcare software provided the client with better corporate alignment, a successfully executed Enterprise Business Assurance strategy, improved overall performance and delivery of both short and long term financial returns.

In terms of process and consumption standardization, EFFY´s software easily identified and quantified cases of potential revenue leakage amongst the various health units. As an example, when looking at which drugs and supplies were used for orthopedic surgeries, most units were losing around 2% - 3% of their potential revenue, with one unit facing losses in the range of 6%. Now these occurrences are being corrected, and each client’s healthcare units actually works as a “unique operator”.

In another case, RAID was able to compare the number of supply kits used with the length of a patient’s stay, across each invoice. Generally speaking, the rule states that one day in the hospital requires the use of one supply kit. EFFY’s software detected that in approximately 4% of cases, these kits where not being properly billed to the respective payer (patient or insurance company). To avoid future cases, risk and compliance processes are being adapted and optimized.

In fact, the RAID tool not only provided an end-to-end solution to mitigate the organizational gaps, but also revolutionized the client’s internal approach.

Going forward, the client’s management team is able to continuously review business process performance, measure and detect deviations from projected levels and provide a rapid transformational response.

“The client ended up creating a new department focused on the implementation and management of their Enterprise Business Assurance strategy, powered by the RAID Healthcare tool”.