Highlights
Challenge: Sustaining strong collections while reducing a heavy reliance on manual claim review and a large RCM staff
Solution: Automate routine billing tasks with a customizable rules engine and exception-based work queues
Outcome: Streamlined revenue cycle operations, lowering staffing costs while maintaining stable cash flow and strong financial performance
A 60-provider pediatric group processing $92 million in annual charges relied on a 25-person RCM team to keep pace with its claim volume. Most of that effort went toward reviewing claims that needed no attention at all. By implementing Encoda’s rules engine and exception-based work queues, the practice automated the routine work, reduced its billing team by 11 full-time positions, and held days in AR steady at 27.
Challenge: manual claim review and rising RCM staffing costs
The pediatric group’s clinical success came with a significant administrative cost. Processing $92 million in annual charges required a 25-person RCM team, and most of that team’s time went toward work that produced little return.
Staff members sifted through thousands of claims, payments, and remittance advices to find the small fraction that genuinely needed intervention. Because nearly every transaction passed through human review, the practice had to maintain a large billing staff simply to keep pace with its volume. This “hunt and peck” approach created persistent bottlenecks and steadily rising staffing costs.
Leadership recognized the pattern. Escalating overhead was eroding the bottom line, and the labor-intensive model could not scale efficiently. The group needed to reduce its staffing costs and streamline its processes without sacrificing collection rates or extending days in AR.
Solution: RCM automation and exception-based workflows
The pediatric group implemented Encoda’s Financial Health Management Platform, shifting from manual claim review to an automated, exception-based model.
Intelligent rules engine
The practice replaced broad manual oversight with Encoda’s rules engine. The engine ingests claim and remittance data, applies logic to validate expected allowables, and posts accurate payments directly into the practice management system. Routine transactions move through automatically, without staff intervention.
Exception-based work queues
Rather than reviewing every claim, the team began managing exclusively by exception. The platform triages incoming work and routes only the complex, high-impact issues—such as payer denials and coding discrepancies—into targeted work queues. This redirected staff time toward the claims that actually required human judgment.
Automated payment validation
Encoda automated the validation and posting of expected remittances, removing the manual data entry that had consumed much of the team’s day. Payments processed faster and with greater accuracy, tightening the path from charge to cash.
Together, these capabilities eliminated the busywork associated with clean claims and concentrated the team’s effort on revenue-generating activity.
Outcome: lower staffing costs, higher productivity, and strong ROI
The shift to automated, exception-based workflows produced measurable gains across staffing, productivity, and financial performance.
Reduced staffing costs
By replacing manual review with system-enforced logic, the practice reduced its RCM team from 25 to 14, producing $550,000 in direct staffing savings.
Higher productivity
Despite operating with a leaner team, the group achieved a 37% gain in overall productivity. Automation absorbed the routine workload, allowing the remaining staff to handle the same claim volume more effectively.
Stable cash flow
The practice maintained a stable rolling average of 27 days in AR, keeping cash flow consistent even as headcount dropped.
Increased collections
Efficiencies created by the platform increased net insurance collections by 1.9%.
Combined, these improvements generated a total cumulative ROI of nearly $2.3 million. The practice now operates a leaner, more scalable revenue cycle — one positioned to absorb growth and adapt to changing payer rules without continually expanding its billing staff.
If your practice is managing rising staffing costs or a growing claim volume, let’s talk through your current revenue cycle and where automation could make a difference.
