Although Pacific Cataract and Laser Institute (PCLI) already had a good clean claims rate, they knew that there was still room for improvement. They were regularly dealing with rejected claims due to minor errors introduced during manual entry, such as policy numbers being entered wrong, incorrect insurance numbers, missed modifiers, and incorrect diagnosis codes.

Correcting these minor errors was a tedious and time-consuming ordeal, but they wanted to see improvements. Rebecca Ashley, Data Entry Team Lead at PCLI explained, “We had a higher number of rejected claims at our clearinghouse than we wanted. Our goal was to be part of the 1% club, meaning an organization with fewer than 1% of claims rejected on a monthly basis.”

However, with 17 locations across six states, any changes to billing and coding procedures had to be communicated to a large team spread throughout the country. Getting everyone up to speed would take significant time and effort. Thus, they needed a solution that would minimize errors and integrate seamlessly across locations.

PCLI worked to implement the NextGen® Charge Review Rules Engine and created a series of custom rules to address their unique billing and coding challenges.

Once the solution was implemented, PCLI began importing their 22,000 monthly encounters. Their 90 custom rules, in combination with the system’s global rules, resulted in a 75% automation rate. This means that 75% of errors were caught and automatically corrected by the NextGen Rules Engine, leaving only 25% for coders to review.

PCLI saw an immediate reduction in claim rejections after implementing the NextGen Rules Engine.

“We implemented in the first week of November and made the 1% club the same month, and then again in December,” Ashley explained.

They also saw a marked improvement in charge processing speed. Their staff no longer had to go in and manually add specific modifiers or correct other issues. The software catches those minor human errors and prevents them from being overlooked. Communication across locations also improved. Rather than having to detail process changes in company-wide emails, they were able to simply create rules to address new requirements. This seamless implementation has resulted in ongoing improvements at PCLI. “Since we implemented the Charge Review Rules Engine, the number of claims for our number one rejection reason with our clearinghouse reduced from 183 in Q2 to 73 in Q4. We implemented it in the second month of Q4—so impressive! And now, that issue is not even in our top 10 rejection reasons,” said Ashley.