OVERVIEW

After implementing eValuator, the client aimed to confirm its financial impact by analyzing 835 remittance data for inpatient claims in the calendar year 2023. A post-payment analysis comparing actual reimbursements with pre-billing predictions validated eValuator’s impact, demonstrating that correcting approximately 2,300 under-coded encounters increased cash for inpatient services by over $31 million.

CHALLENGES

• Validate Pre-Bill Financial Projections
  Pre-bill projected reimbursements provided estimates of financial impact but not actual reimbursements across payors.
• Quantify Bottom Line Impact
  Without actual reimbursement data, it was challenging to validate eValuator’s true bottom-line impact to the executive team.
• Validate Coding Accuracy Improvements
  Actual reimbursement data from eValuator’s pre-billing coding changes was needed to verify coding accuracy improvements.

GOALS

• Leverage 835 Remittance Data to Validate Pre-Bill Projections
  Compare actual reimbursement data using 835 remittance data with eValuator pre-billing predicted impacts to confirm the accuracy of projections.
• Aggregate Actuals by Payor to Quantify Bottom Line Impact
  Quantify eValuator’s true impact on the organization’s financial performance and prove the return on investment to the executive team.
• Validate Coding Accuracy for Potential Auditing Expansion
  Confirm coding accuracy improvement to make a case for potentially expanding the audit staff to further optimize cash capture.

OUTCOMES

• Confirmed $31M Total Cash Impact
  Analysis shows eValuator optimized around 2,300 under-coded encounters, capturing $31 million in cash and averaging $14K per correction.
• Actuals Exceeded Pre-Bill Projections
  The executive team concluded that actual financial impact exceeded eValuator’s pre-bill projections.
• Cost Avoidance & Savings
  By identifying issues pre-bill, client avoided potential rebilling costs & contingency fees of 20–40%, saving $6–12 million from the $31 million.