Success Story Healthcare

Emergency Department Improves Claim Coding to Increase Revenues

The deployment AI-based tool for predicting the erroneously coded chart

The client operates ER (Emergency Department) across the US. The revenue per year is $22M with an average of 18,000 visits per month. They have a collective total of 45 billing/collections staff, both onshore and offshore.

The client incurred revenue loss due to inaccurate charging and coding processes for (ED) patients. The inconsistencies and reduced quality of the processes not only hindered the performance but also lead to denial of claims. The deployment AI-based tool for predicting the erroneously coded chart and generating audit samples led to improvement in accuracy, consistency in coding, and error prediction. It also enhanced revenue, while also lowering costs, reducing the number of failed claims, and improving coding accuracy.

The challenge

7 key areas

Filing Denials

Filing Denials Timely filing denials due to delay in receiving documentation and missing charges

Denials & Information Issues

Denials & Information Issues High rate of eligibility related denials and incomplete demographic information

Coding & Quality Issues

Coding & Quality Issues Inconsistency in coding performance and drop in quality

Coding & Quality Issues

Underpayment Tracking The non-tracking of several underpayment issues

Denied Claims

Denied Claims Denied claim due to charge and coding issues

Reduced Acuity & Revenue

Reduced Acuity & Revenue Reduced acuity and revenue per encounter

Compliance Risks

Compliance Risks Unidentified compliance risks

The Solution

5 key areas

Based on the assessment, the Apexon team recommended the following technology initiatives to transform the reconciliation and quality procedures:

Improve Coding

Improve Coding

Usage of technology such as assisted coding and error prediction tool to improve accuracy and consistency in coding

Training for Coding Denials

Training for Coding Denials

Trained the team on coding standards and implementing process guidelines to handle regular coding denials

High-level Reporting Solution

High-level Reporting Solution

Implementing high-level reporting solution to identify and address anomalies

Eligibility Verification

Eligibility Verification

100% eligibility verification before submitting a claim to the payer

Improved Process Efficiency

Improved Process Efficiency

Change in the workflow to improve the overall process efficiency

A strategic approach towards quality led to the creation of an AI-based automation tool. This resulted in accurate and timely predicting of the erroneously coded chart and generating audit samples which were crucial in improving the performance and revenue. It delivered the following:


It helped maintain manually-coded and auto-coded sheets based on daily coded data and corresponding audits


Performed as an error prediction tool with customizable algorithm for predicting error codes and the likely reason for the inaccuracy


It helped in prioritizing error charts with maximum error propensity across different critical to quality fields


It helped in generating reports and monitoring quality with an eye on improving the coding process