Practice Profile
- Specialty: Gastroenterology
- Size: 12 physicians, 3 advanced practice providers
- Location: Phoenix, Arizona
- Annual patient volume: ~27,000 patients
- Procedures: 13,500+ endoscopic procedures annually
Challenge
Valley Gastroenterology Associates (VGA) struggled with a denial rate that had climbed to 19.3% by Q3 2023, significantly above the specialty average of 12%. Their four-person billing team was overwhelmed with denial management, spending 65% of their time working rejected claims rather than focusing on optimization and patient financial services. Most concerning was their high final denial rate – 38% of initial denials were never recovered, resulting in permanent revenue loss of approximately $42,000 monthly.
Specific pain points included
- Endoscopic procedure coding errors resulting in frequent denials
- Inconsistent documentation patterns across 12 physicians
- Difficulty keeping up with changing payer requirements
- High volume of prior authorization denials
- $1.2M in accounts receivable over 90 days old
Primrose.health Solution
VGA implemented Primrose.health’s AI-powered revenue cycle management platform in October 2023, focusing on three key areas:
1. Pre-submission claim analysis
- AI-based review of all claims before submission
- Pattern-matching against 3.4 million historical GI claims
- Automated correction of common coding errors
2. Documentation improvement
- Implementation of specialty-specific templates
- AI-assisted coding recommendations
- Real-time feedback on documentation gaps
3. Payer-specific optimization
- Custom rules for top five payers
- Authorization verification workflow
- Denial pattern detection and prevention
Results:
| Metric | Before Primrose.health | After 6 Months | Improvement |
|---|---|---|---|
Overall Denial Rate | 19.3% | 11.2% | 42% reduction |
First-Pass Clean Claim Rate | 74.2% | 93.8% | 26.4% increase |
Days in Accounts Receivable | 38.6 | 22.3 | 42.2% reduction |
Authorization-Related Denials | 42 per month | 7 per month | 83.3% reduction |
Monthly Collections | $1.42M | $1.73M | 21.8% increase |
90+ Day A/R | $1.2M | $412K | 65.7% reduction |
Financial Impact:
- Additional revenue captured: $385,000 in the first year
- ROI: 735% in first 12 months
- Billing staff efficiency: 62% more claims processed per staff hour
Practice Administrator Quote
“Before working with Primrose.health, our billing team was constantly in reactive mode, fighting denials after the fact. Now we prevent most denials before they happen. The AI identifies issues we would never catch manually, and our staff can focus on the complex cases that truly need human expertise. The financial impact has been significant, but equally important is the reduced stress on our team and the improved patient financial experience.” – Maria Cordova, Practice Administrator, Valley Gastroenterology Associates.