Practice Profile
- Specialty: Cardiology
- Size: 17 cardiologists (9 interventional, 8 non-interventional)
- Location: Multiple locations across Ohio and Michigan
- Annual patient volume: ~35,000 patients
- Annual procedures: 3,200+ catheterizations, 8,500+ echocardiograms
Challenge
Midwest Cardiology Partners (MCP) faced a critical revenue cycle challenge with denial rates reaching 23.7% in early 2023, well above the specialty average. Their particular challenges included complex coding for interventional procedures, frequent medical necessity denials for diagnostic testing, and delayed claim submissions resulting in timely filing issues. With over $2.1M in accounts receivable beyond 90 days and an average of 41.3 days to payment, cash flow constraints were limiting practice growth and investment in new technology.
Specific pain points included
- High volume of medical necessity denials for cardiac imaging
- Complex bundling issues with catheterization procedures
- Inconsistent modifier usage across multiple providers
- Documentation gaps for high-cost procedures
- Staffing challenges with 2 billing positions unfilled for 7+ months
Primrose.health Solution
MCP implemented Primrose.health’s AI-powered medical billing platform in February 2023:
1. AI-powered documentation analysis
- Natural language processing to identify documentation gaps
- Automated alerts for medical necessity issues before claim submission
- Cardiology-specific coding recommendations
2. Procedure-specific claim optimization
- Specialty rules for cardiac catheterization coding
- Bundling/unbundling detection
- Modifier optimization for complex cases
3. Denial prediction and prevention
- Pre-submission claim scoring
- Payer-specific rule engine
- Authorization verification workflow automation
Results:
| Metric | Before Primrose.health | After 6 Months | Improvement |
|---|---|---|---|
Overall Denial Rate | 23.7% | 12.5% | 47.3% reduction |
First-Pass Clean Claim Rate | 68.3% | 92.1% | 34.8% increase |
Days in Accounts Receivable | 41.3 | 19.8 | 52.1% reduction |
Medical Necessity Denials | 97 per month | 23 per month | 76.3% reduction |
Monthly Collections | $2.37M | $2.82M | 18.9% increase |
90+ Day A/R | $2.1M | $615K | 70.7% reduction |
Financial Impact:
- Additional revenue captured: $675,000 in first year
- ROI: 812% in first 12 months
- Staffing efficiency: Able to manage increased volume with 1 fewer FTE
Medical Director Quote
“The complexity of cardiology billing made our previous denial rate almost inevitable. What’s impressed me most about Primrose.health is how their AI actually understands the nuances of cardiovascular procedures and documentation requirements. We’ve not only seen a dramatic financial improvement but also reduced the administrative burden on our physicians. The system learns our documentation patterns and provides specific guidance rather than generic advice. It’s like having a world-class coding expert reviewing every chart.” – Dr. James Rutherford, Medical Director, Midwest Cardiology Partners.