Carenox HealthCarenox Health

RCM Diagnostics

Lift clean-claim rate, shrink denials, and speed cash. We baseline your metrics, map exceptions, design QA & coverage, and hand you a pilot plan you can run—or we can run it with you.

Our ApproachWhat You Get
Baseline
  • Clean-claim rate (first-pass), edit hit rates, and rejection reasons
  • Top denials by payer, code, and root cause (front vs. back end)
  • Submission TAT (charge → payer), rework %, and AR aging buckets
Map Exceptions
  • Eligibility, auths, coding, and charge entry exception flows
  • Edits matrix: payer rules, clinic rules, clearinghouse rules
  • Ownership/RACI for fixes; feedback loops to front desk & coding
Design QA & Coverage
  • Defect classes + AQL targets; calibration cadence and checklists
  • Coverage grid sized to arrivals; surge buffers for peaks & outages
  • Evidence tiles linking claims to validations and corrections
Pilot Plan
  • 2–4 week pilot with success thresholds and rollback criteria
  • Dashboard tiles: CCR, TAT p50/p90, denials Pareto, rework %
  • Scale path: lanes to move into managed delivery with SLAs

What You Receive

  • Findings deck with metrics baseline and denial Pareto
  • Versioned SOPs & exception flows (auths, charge, submit, rework)
  • QA rubric: defect classes, AQL targets, calibration plan
  • Coverage model: shift grid, surge buffers, recovery windows
  • Pilot blueprint with success criteria, risks, and owners

Metrics We Target

  • Clean-Claim Rate (CCR) and First-Pass Acceptance
  • Submission TAT (charge entry → payer submit)
  • Clearinghouse rejections & rework TAT
  • Denials rate and overturn yield by class
  • AR aging deltas (30/60/90+) and cash acceleration

Common Pilot Shapes

Lane
Charge Entry + Submit

Daily charge entry with edits pre-scrub; rejections reworked in 24–48h.

Lane
Denials & Appeals

Root-cause fixes and payer-specific appeals with evidence packaging.

Lane
AR Follow-Up

Worklists by aging; contact matrix; underpayment flags and resubmits.

Lane
Eligibility & Auths

Real-time checks, auth tracking, and handoff fixes to front desk.

Want a clean-claim lift in weeks?

We’ll run a 1–2 week diagnostic and propose a pilot with CCR, TAT, and denial-reduction targets.

Talk to an RCM LeadStart an Assessment