“Enhanced Claim Status will provide you with more information extracted directly from the payer site that you will not get in a regular claim status.”
—Jake Reid, Senior Director of Revenue Cycle Business Offices at St. Luke’s Health System
Challenge
St. Luke’s Health System is Idaho’s largest healthcare provider, handling over three million outpatient visits per year and processing more than 450,000 claims per month. As the organization grew, rising patient volumes put pressure on staff to keep billing processes running smoothly. They needed a scalable solution to manage claims follow-ups without increasing headcount or compromising patient care.
“We had a growing population and an increase in accounts receivable (AR),” says Jake Reid, Senior Director of Revenue Cycle Business Offices at St. Luke’s. “We couldn’t keep up. To continue to fulfill our mission to support our communities and stay financially sound, we needed a more efficient way to collect revenue.”
They focused on four key questions:
- How can we maximize staff efficiency by improving post-claim follow-up?
- How can we leverage technology to handle growing account volumes without increasing headcount?
- How can we avoid wasted touches so staff can focus on accounts that require follow-up?
- How can we accelerate AR recovery to improve cash flow and reduce aging?
Solution
After exploring in-house and outsourced options, St. Luke’s decided to implement Experian Health’s Enhanced Claim Status to automate and streamline the claims follow-up process. The tool pulls adjudication data directly from payer sites and delivers detailed claim statuses within Epic, eliminating the need for staff to manually track claims through payer portals or wait for remittances.
What started as a pilot with just one payer quickly expanded to include other high-impact payers. The team liked how Enhanced Claim Status provided real-time insights into denied, rejected and pending claims, so they were able to prioritize and resolve issues sooner. Claims are automatically routed into work queues based on customized rules, accelerating follow-up by one to two weeks. This allowed staff to focus on the right accounts and reduced unnecessary work.
Reid says, “Enhanced Claim Status will provide you with more information extracted directly from the payer site that you will not get in a regular claim status.” The team values this richer data, which includes enhanced data like proprietary reason codes and actionable explanations for each claim. St. Luke’s worked closely with Experian Health to ensure all necessary fields were captured from payer responses and set up for payers not already supported, so no claims were overlooked. They were able to set their own rules for status checks, retry intervals and cutoff points, and claim status codes were categorized to determine the most appropriate work queue, based on St. Luke’s own requirements. All payer responses are automatically formatted in a consistent way, so staff can continue to work efficiently, no matter how many new payers are added.
Read the blog: 6 steps to improving the claims adjudication process
Outcome
Shifting to automated claim status checks significantly reduced the administrative burden, achieving the following financial results:
- Denials dropped by 76%, falling from 27% to just 6.5% since 2017
- “Discharged/not billed” accounts were reduced by $15 million per month
- Hospital billing aged over 90 days now consistently meets Epic’s Silver or Gold benchmarks, with the watch list down from an average of $13 million to under $1 million since going live in 2019
- Patient billing over 90 days now sits at just 4.5%, putting St. Luke’s among the top performers of Epic users
Automation also helped St. Luke’s save the equivalent of three full-time staff each year. With fewer unbilled accounts and more efficient workflows, the overall cost to collect went down. Staff appreciated having better data and more time to focus on complex accounts, which increased their capacity to support patients directly.
Reid says that with Enhanced Claim Status, the organization has successfully achieved its goal of accelerating AR resolution and denials management, without overburdening staff. He attributes this to continuous testing, improvement and close collaboration with Experian Health:
“Much of our success came from customizing the build to our workflows and processes. You will lose momentum and staff buy-in if you don’t ensure the build is solid. The importance of testing cannot be underestimated. Finally, ensure you are checking in with Experian often to address any issues that arise. Experian has always been very responsive to my teams and I’d expect that to be the same for you.”
Find out more about how Enhanced Claim Status accelerates claim follow-up and improves cash flow.
