restructuring RCM systems

Restructuring Specialty Pharmacy RCM Systems to Root Out Variances

restructuring RCM systems
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AgileThought Systematically Eliminates Bad Debt & Revenue Variances Through Revenue Cycle Management (RCM) System Updates & Automation


AgileThought has worked with this leading PBM customer for over fifteen years, and has gained extensive knowledge of specialty pharmacy processes.

Payment option variances were causing billing errors and revenue losses. AgileThought eliminated revenue variances via thorough process and system analysis, and provided a seamless and integrated solution to prevent future errors, including an early warning system designed that leveraged machine learning and predictive analytics to detect potential bad debt scenarios before they occurred.

AgileThought provided the PBM with reliable RCM practices including data restructuring, updating processes, automation and introduced new platform technology, all which accelerated reimbursement and reduced financial risks.

The Challenge

It was difficult for the PBM to clearly identify the proper insurance plan for a single patient as their RCM system prompted several options. System users (mostly patient care advocates or PCAs) were seeing between thirty and fifty plan options per patient when there should only be one.

PCAs were sorting through 30-50 plan options per patient when there should have been one clear option presented to them upon review. The RCM solution required enabling the system to update patient insurance data, payer data, and front-end processes in real time.

If an incorrect payer option was selected, it would take between 60 and 90 days to correct the billing mistake. By the time the correct payer was billed, they would cite overdue service-level agreements and other contractual agreements, nullifying their responsibility.

The PBM would have had no choice but to absorb the costs, which would’ve added up to thousands of dollars per patient in the Specialty Pharmacy division.

AgileThought was called on to:

  • Analyze the causes of bad debt
  • Improve intake functionality
  • Close gaps on RCM processes
  • Provide faster reporting and data analysis
  • Reduce bad debt costs absorbed by the PBM

Calling in the Subject Matter Experts

The platform in which the RCM systems lived was dated. The PBM decided to restructure their systems on a more modern platform, which was easier to support and more intuitive for users. The RCM project would spearhead a larger digital transformation effort, which included:

  • New platform technology
  • Data restructuring
  • Updated processes
  • Automation

New Platform Technology

AgileThought grew its Pega skillset to the point that the team had been asked to replace other Pega vendors due to their distinct knowledge of the legacy platform and RCM processes.

The team leveraged database and systems load knowledge to create an ECS (enterprise-class structure), giving them an optimal model to restructure payer setup.


The size of the legacy system database, and how overly indexed it was, posed a major challenge. AgileThought designed new system architecture and a nimble table structure that was easier to support. Users can now match the correct payer information with each patient and treatment plan.

In the past, the payment system would show multiple plan options to PCAs. Information is now filtered through a hierarchy of data such as insurance name and plan name. This information was further correlated with payer information, the prescription or product line, and the medication itself. Users can now match the correct payer information with each patient and treatment plan. Cost benefits from the more organized structure are projected to add up to tens of millions of dollars.

Automation & Machine Learning

The data management and IT teams weren’t the only people to call on AgileThought’s insight. Finance worked with AgileThought to clarify revenue variances and detect anomalies.

Automation was essential to accelerate the RCM transformation. AgileThought is currently automating deployment components and part of the QA process, which will improve the new system’s performance, testing, and accuracy.

In addition to automated system components, AgileThought is building a risk evaluator system to deter future revenue variances and bad debt. The risk evaluator will be analyzing data trends to detect risk factors. An intelligent algorithm will learn patterns to predict issues across patient data and payer contracts, and flag any potential issue.

Why Healthcare Turns to AgileThought for RCM

With the new platform and processes in place, the PBM specialty pharmacy division has eliminated revenue variances, and can detect future risks. Cost benefits from the new RCM platform are projected to be tens of millions of dollars.

RCM transparency is more important than ever as spending on prescription medication is projected to hold at 2 to 5 percent through 2021.

AgileThought has over a decade of healthcare operational and consultative experience. Our team will root out causes of inefficiency, and then dive under the hood with technical, cost-effective resources to build a lasting solution. Deliver on your digital business mandates, accelerate your next IT project, and pay less.

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restructuring RCM systems

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