Highlights
Challenge: Scaling for growth without adding RCM staff while reducing costly J-Code claim denials and limited financial visibility
Solution: Automate claims scrubbing, route work by exception, and consolidate revenue cycle data into real-time analytics
Outcome: Streamlined revenue cycle operations, supporting growth and accelerating cash flow without expanding the billing team
A growing six-provider ophthalmology group needed to handle a rising volume of charges without expanding its revenue cycle team. Manual workflows and persistent J-Code denials were slowing the practice down and draining revenue. By implementing Encoda’s rules engine, exception-based work queues, and RCM analytics, the group automated routine work, cut days in AR from 30 to 21.6, and grew total charges by $2.17 million, all while holding headcount steady.
Challenge: J-code denials, manual RCM workflows, and limited visibility
The practice was preparing for growth, and its leadership knew the existing revenue cycle wouldn’t scale with it. The practice wanted to handle a larger volume of more complex claims with the same six-person RCM team, but its manual processes stood in the way.
Staff spent hours sifting through healthy claims to find the few that needed attention. That reactive approach created bottlenecks in payment posting and AR follow-up, and it left little room to absorb additional volume.
J-Code denials made the problem worse. These codes are notoriously difficult to process and frequently trigger payer audits and rejections. The practice’s outdated scrubbing methods caught only the most obvious errors, trapping the team in a repeating cycle of denial and rework.
Leadership also lacked the visibility it needed to manage proactively. Without clear reporting, administrators couldn’t easily see where revenue was delayed, underpaid, or at risk, which made strategic, data-driven decisions difficult.
Solution: claims scrubbing automation, work queues, and RCM analytics
The practice implemented Encoda’s financial health management platform, automating routine work and giving leadership a clear view into revenue cycle performance.
Intelligent claims management
The practice deployed a multi-layered scrubbing process built on Encoda’s rules engine. Rather than relying on generic edits, the team configured the engine to catch and correct J-Code errors before submission. The automated logic resolves missing modifiers and coding discrepancies upstream, preventing denials before claims reach the payer.
Exception-based work queues
Encoda restructured the team’s daily work around exceptions. The platform automatically triages and routes only the claims that genuinely need human intervention, eliminating the time staff once spent hunting through clean claims. That freed the team to concentrate on high-value accounts.
RCM analytics
Encoda consolidated the group’s siloed financial data into a single system of record. Leadership now has continuous visibility to monitor performance, prioritize high-value claims, and optimize operations without relying on fragmented spreadsheets.
Outcome: cleaner claims, faster cash flow, and scalable growth
The shift to automated, exception-based workflows produced measurable gains across claim accuracy, cash flow, and productivity.
Cleaner claims
The rules engine limited denials and lifted the practice to a 93% first-pass claim pay rate, with J-Code errors resolved before submission.
Cash flow efficiency
Over five months, days in AR dropped from nearly 30 to an average of 21.6. Net collections also rose 3.42% over the prior six-month period.
Growth without added headcount
The practice grew total annual charges by $2.17 million while keeping its RCM team the same size, a 14% productivity gain.
The group now runs a leaner, more scalable revenue cycle and can continue refining its billing rules as it grows.
If your practice is preparing for growth or losing revenue to complex denials, let’s talk about your current processes and how Encoda can help.
