Path A
Staffing → Managed
Start with pods and QA; migrate stable lanes (rejections, AR follow-up) to SLAs once benchmarks hold.
Compare Models
Choose the right fit for your RCM lanes now—and the upgrade path as you scale outcomes.
Side-by-Side Comparison
| Dimension | RCM Staffing Pods | Managed Outcomes | Diagnostic & Playbook |
|---|---|---|---|
| Primary Use | Add calibrated RCM capacity on your EMR/PM (eligibility, charge entry, claims + rejections, AR/denials, prior auth, coding QA) using your workflows. | Buy outcomes for specific lanes with SLAs (TAT, accuracy, clean-claim %, win-rate, AR aging). We run SOPs, QA, coverage, governance, and dashboards. | Time-boxed Diagnostic/Playbook to lock scope, defect taxonomy, coverage math, and dashboard definitions; produce a pilot plan with owners and dates. |
| Commercials | Hourly/W-2 per FTE pod; surge options for peaks. | Per-lane monthly unit price or per-transaction; SLA incentives/credits. | Fixed-fee (1–4 weeks depending on artifacts and access). |
| Quality | AQL sampling, shared defect classes (payer edits, NCCI/modifiers, LCD/NCD), reviewer calibration cadence. | Risk-based AQL + dual review on high-risk items (high-$ claims, appeals). Immutable evidence tiles linked to policy, notes, and artifacts. | Design the defect taxonomy, AQL targets, sampling plan, and drift-check cadence; exemplars for alignment. |
| Coverage | Shift grid matched to clinic schedule; cross-training and surge buffers sized to forecast error. | Contracted service windows with surge guardrails; adherence dashboards and continuity playbooks. | Coverage math by interval, buffer sizing from arrival variability; WFM guardrails and escalation thresholds. |
| Dashboards | Throughput, QA %, backlog/aging; definition locks to prevent metric drift. | SLA attainment (p50/p90), accuracy, defect mix, clean-claim %, win-rate; drill-to-evidence for audits/coaching. | Tile spec (owner, refresh, formula), source-of-truth mapping, mockups ready to implement. |
| Change Control | Ticketed SOP/policy updates with versioning and training attestations. | Versioned SOPs tied to evidence; weekly ops review, PIRs, and continuous-improvement backlog with owners/dates. | Change-log and RACI templates; readiness gates for pilot → scale. |
| Time to Start | Fast (days–weeks) after access and (if needed) BAA execution. | Usually after a short pilot or calibrated run; weeks from scope lock. | 1–4 weeks based on discovery depth and existing artifacts. |
| Best For | Eligibility/benefits, charge entry, claim scrub & rejections, AR follow-up, prior auth desks, coding QA support. | Denials & appeals programs, clean-claim uplift, prior-auth turnaround, 30/60/90+ AR aging recovery, coding-quality programs. | When stakeholders need alignment and a pilot blueprint before scaling lanes on SLAs. |
Definition locks travel with metrics across models to prevent drift. Evidence tiles enable fast audits and objective coaching.
Path B
Diagnostic → Pilot → Managed
Run a 2–4 week Diagnostic; pilot with success gates; scale on outcomes (great for denials programs and prior-auth desks).
Path C
Hybrid
Keep internal production, add staffed QA + dashboards; convert selective lanes (appeals, high-$ claims) to SLAs.
FAQs
Can we start with Staffing Pods and move to Managed Outcomes later?
Yes. Many clients begin with staffed pods (shared definitions + QA); stable lanes then migrate to Managed Outcomes once benchmarks hold and SLAs can be contracted.
How do dashboards differ across models?
Definitions remain consistent. Managed Outcomes adds SLA attainment and drill-to-evidence; Staffing focuses on throughput/QA/backlog. Diagnostics deliver the definition catalogue so metrics don’t drift.
What about HIPAA/BAA and PHI?
We execute BAAs when PHI is in scope, operate least-privilege access with audit trails, and embed evidence links so audits and coaching are fast and objective.
How do pilots work?
We agree success metrics, sample sizes, and go/no-go gates. Pilots can be staffed or managed; a Diagnostic is ideal when scope or definitions need alignment first.
Next Step
If scope is clear, request a Managed Outcomes proposal. If not, start with a short Diagnostic to lock definitions and success criteria.