Healthcare claims processor achieves 95% success rate for customers with Sisense analytics

Meet efficientC

Unpaid claims payments are one of the biggest causes of revenue loss for hospitals and healthcare providers. To help reduce errors when processing claims, healthcare providers use claims scrubbers (data checking software) to ensure that claims that leave the door have the best chance of getting paid, ideally the first time they are submitted. In 2009, Lori Zindl, the CEO and founder of the claims processing company OS Healthcare, developed efficientC, a software platform with denial prevention technology that accelerates revenue generation for hospitals. efficientC combines the capabilities of a clearinghouse and claims scrubber with the power of analytics, enabling hospitals and healthcare providers to get their claims paid by insurers faster, with fewer claim denials.  

efficientC’s challenge: Improve ease of use and optimize performance to increase customer adoption of analytics 

The medical billing process in the United States is particularly challenging. If a claim is denied by insurance the first time, it has a 60% chance of being denied a second time and an increased chance that it will never get paid. The cost of reworking a claim can average as much as $118 per claim, according to Becker’s Hospital Review, leading to reduced profitability.  

Before switching to Sisense, efficientC used a different embedded analytics solution, but “found that it was inefficient and wouldn’t scale. It was a challenge to get our customers to adopt and use the dashboards.” says Lori Zindl. They wanted a solution that would make it easy for both external and internal end-users to get their insights faster, be quick to implement with fewer staff, and scale over time.

efficientC’s immediate and ambitious goal is to help its customers increase their First Pass Yield Rate (percentage of claims paid at first submission) from an industry average of 75-80% to upwards of 90-95%. 

Using Sisense to achieve customer experience excellence

“With Sisense, we immediately were able to give life to a whole lot of powerful use cases and options that were conceived by our customers and our founder Lori,” says Michael Schram, Director of Product Development & Strategy at efficientC. The company presents healthcare providers a complete and comprehensive view of crucial KPIs using their Sisense-powered analytics tool, Insights. Customers now have rich, interactive dashboards to explore data and track payment trends in the revenue cycle, and flag them if they’re falling behind.

Sisense also provides efficientC with the agility and flexibility to rapidly tackle multiple challenges to scale. For example, it would typically take 20 minutes to manually run a report based on 6-months data for a customer. Now the same report, which is also automated, takes 5-10 seconds per load, and even less time with smaller datasets. With reduced time to insight, customers have the ability to achieve more with less. One hospital customer reduced claims denials by nearly 40% within six months of adoption.

Further, with intuitive and easy to use dashboards, usage and adoption skyrocketed. “Our dashboards are now used every day by most end-users,” reports Lori. Adds Michael, “The simplicity with which we can move and the speed with which we can move is great. And now we can offer that to our customers as part of our value proposition.”    

Going for Gold 

Following its culture of innovation, Sisense has helped efficientC successfully differentiate its product from the competition. Michael uses the analogy of an Olympic figure skater to explain their approach in an emerging healthcare/billing technology space crowded with similar offerings. “It isn’t enough to be the most technically gifted figure skater. You have to pull in all the technical elements with speed, fluidity and flair to win the gold,” he says. “So as a clearinghouse, you could have all those technical capabilities like the rest of the competition, but the key to success is to integrate it for the customer seamlessly and with a great presentation.”

The results speak to the success of efficientC’s approach and strategy: 95% of customers’ claims get paid within 20 days or less, an average 15% cash flow improvement for customers, a 40% reduction of denials in 60 days of implementation, and increased cash collections with decreased write offs. 

efficientC is also ready for the next stage of its business evolution — becoming an analytics-driven company, enabling cash flow predictions for customers with Sisense’s AI-driven forecasting capabilities. 

“We truly have the best product out there in the denial prevention space. Because of our partnership with Sisense, and their analytics platform, we really have taken it to the next level. Sisense has been a game changer and will continue to be as we move forward and extend our brand into the analytics and AI space.” 

Michael Schram, Director of Product Development & Strategy, efficientC