The Challenge
A major women's and children's hospital was losing millions in revenue it had legitimately earned but never collected. An audit revealed widespread gaps in billing practice: insurance coverage was not consistently verified, estimates were rarely generated, pre-authorizations were missed, and payments were not collected at the appropriate points in the patient journey.
The cumulative effect was substantial revenue leakage and operational inefficiency that threatened the hospital's long-term financial sustainability. Without reliable revenue processes, the organization's ability to invest in patient care was at risk.
The Approach
A comprehensive review of inpatient and outpatient workflows exposed inconsistencies at every stage of the billing cycle. Improvements were organized into short-, medium-, and long-term workstreams:
- Standardized processes were established for estimate generation, pre-authorization, payment collection, coding, and claim submission
- Charges were standardized and updated on a regular cycle using accurate cost data
- Payer agreements were reconciled and aligned with the hospital's new pricing structure
- Training was delivered to clinical and administrative teams to build shared understanding of the new processes
- Governance mechanisms were introduced to monitor compliance and sustain improvements over time
The Outcome
The transformation delivered approximately $25 million in financial benefits, dramatically improving revenue integrity and reducing the variability that had previously made forecasting unreliable.
Transparency between clinical and administrative functions improved, and the hospital emerged positioned for long-term financial sustainability with the systems, standards, and governance structures needed to protect and grow its revenue.