How we helped our client with pre-authorization, increased their clean claim ratio and provided on-site workforce support.

RCM Pre-Authorization Highlights

Client Overview
This client is a mid-sized home care provider in the United States. They offer a wide range of home care services including skilled nursing services, physical therapy and occupational therapy.

Business Challenge
This client has an average of 300 to 350 patients every month requesting prior authorization. Owing to staff shortages and the need to obtain pre-authorization, often on short notice, the client was faced with the challenge of following up and obtaining pre-approval in a timely manner. Follow-up with payors was overwhelming and they were looking for a business partner that could consistently provide hassle-free support that both met the client’s expected internal KPIs related to RCM and was respectful of the time-sensitive nature of the work .

How Do We Help with Pre-Authorization?
Red Road Health Solutions offers clinical and non-clinical business solutions to home healthcare providers and understands payor specific, federal, and state requirements for pre-authorization, as well as providing the full scope of Revenue Cycle Management Services.

Red Road Health Solutions’ experts in pre-authorization verify the eligibility and benefits of the assigned patients. Based on eligibility and benefits, they follow up with the payor by sending the required medical documents (485, clinical notes and visit notes and the payor-specific authorization form). Red Road also follows up with the payor to check the status of the request. Once the request has been approved, the approval letter is uploaded to the patient’s file and Red Road contacts the client’s relevant office(s) to let them know how to proceed.

In case of any held or denied authorization Red Road follows up with the payor via calls in order to identify the actual cause and coordinate with client, taking any further required information and submitting the appeal.

We also raise extension of authorization in a timely fashion.

Key Areas we focus on:

  • Red Road helps to do a pre-analysis before initiating an authorization request by checking whether we have all the required documents and information.
  • Always following payor, CMS guidelines. Submitting the pre-authorization request on time helps our client to ensure the claim will be accepted by the payor.
  • Red Road regularly follows up with the payor and keeps the client informed of the status of the authorization request.
  • If an application is denied or rejected, Red Road expects it to be investigated for a key reason and will take appropriate action by filing an appeal or re-submitting the application.
  • Red Road keeps consistently up to date with the guidelines and learns from any denials and rejections.

Turn Around Time
From the date of request, Red Road is required to obtain authorization based on payor specific timelines. This includes, on occasion, raising authorization within 24 hours for this client and prioritizing their request.

Red Road Health Solutions helped the client obtain prior approval by setting deadlines on a caseby-case basis. This resulted in the client receiving appropriate payments for the services rendered. It has also lowered the number of denials by 12 %, over a period of 14 months. Red Road helped this client apply for authorization on time, increase the clean payment ratio, reduce rejections, and helped with support for on-site workforce issues.


Review Choice Demonstration (RCD) Case Study | Red Road

Client Overview

This client is home health care provider in the United States. They offer a wide range of home care services, including home health and skilled nursing services.

Business Challenge

Red Road Health Solutions offers excellent clinical and non-clinical back-office support solutions to home healthcare providers and understands payor specific, federal and state requirements for pre-claim reviews for Review Choice Demonstration, Medicare ICD 10 coding, and RCM. We were enlisted to work directly in the client’s EMR, thus improving the efficiency and effectiveness of the review process.

How Do We Help with Pre-Claim Reviews?

The home health claims from this client had issues during the initial Pre-Claim Review (PCR) cycles, as they had multiple deficiencies with the face-to-face documentation, orders and SMART goals, due to inconsistencies in the interpretation of the payer (Palmetto) requirement. To address this on an ongoing basis for this client, Red Road carries out a complete audit (100%), which enables the client to continuously monitor the documentation process and significantly reduce the risk of denials.


Review Choice Demonstration – Pre-Claim Review, Packaging and Submission

The client had issues with the initial PCR cycles with an affirmation percentage of less than 85%. Red Road has been providing pre-claim reviews, packaging and submission of charts for our client under the Review Choice Demonstration (RCD). The client has been able to meet the following goals with Red Road’s support:

  • Red Road helps to clear 400 claims monthly with an affirmed UTN.
  • A significantly improved and consistent affirmation Rate of 98% due to the extensive review and feedback process, ensuring all relevant information is in the package prior to submission.
  • Improved office efficiency, as the packaging of charts is handled by Red Road.
  • Red Road reviews identified deficiencies which enabled the client to give specific feedback to their clinicians, resulting in consistent improvement in documentation and clinicians feeling more supported by the client.
  • The Red Road team helped the client to avoid write offs.
  • The client was put on track to come out of 100% PCR 6 months after commencing reviews with Red Road.