How QWay Healthcare Eliminated CO-119 Denials and Improved Claim Accuracy with AI-Driven RCM
When recurring frequency-based denials began delaying reimbursements and increasing administrative burden, a multispecialty medical group partnered with QWay Healthcare to prevent errors before claims were submitted.Overview
A multispecialty medical group in Northern California was facing persistent challenges with Medicare claim denials related to screening colonoscopy procedures. Despite ongoing billing efforts, the organization struggled with frequency-based denials due to incomplete patient screening histories and inaccurate validation of payer requirements before submission. These issues led to delayed reimbursements, increased administrative workload, and ongoing revenue leakage. The organization needed a more proactive and reliable approach to denial management. QWay Healthcare was engaged to implement an AI-driven revenue cycle management strategy focused on preventing denials before they occurred.Impact & Key Metrics
- Recurring CO-119 frequency-based denials were eliminated
- Claim accuracy and compliance improved
- Reimbursements were accelerated
- Administrative workload for billing teams was reduced
- Overall revenue cycle performance improved
Challenge
The organization was experiencing repeated Medicare denials tied to colonoscopy screening claims, specifically related to frequency limitations. Several operational gaps contributed to the issue:- Patient screening histories were incomplete or not consistently validated
- Claims were submitted outside Medicare’s allowed screening frequency limits
- Payer rules were reviewed manually, increasing the risk of error
- CO-119 denials continued to recur without a clear prevention strategy
- Billing teams were burdened with rework and manual corrections
Solution
QWay Healthcare implemented an AI-enabled revenue cycle management framework designed to identify and resolve issues before claims were submitted.AI-Based Frequency Validation
Automated checks validated patient screening histories to ensure colonoscopy claims met Medicare frequency requirements prior to submission.Payer Rule Intelligence
Payer-specific guidelines were integrated directly into the billing workflow, enabling real-time verification of claim eligibility.Denial Pattern Analytics
AI analyzed historical denial data to identify patterns behind recurring CO-119 denials, providing clarity on root causes.Automated Workflow Optimization
Manual review steps were automated, allowing billing teams to proactively correct errors before submission.Results
Before QWay Healthcare:
The organization faced recurring CO-119 denials, delayed reimbursements, and a growing administrative burden. Claims were often submitted without fully validating screening history or payer requirements, leading to repeated errors and revenue leakage.After QWay Healthcare:
The organization shifted from reactive denial management to proactive denial prevention. Recurring CO-119 denials were eliminated, and claim accuracy improved as validation processes were automated and standardized. Reimbursements became faster as fewer claims were rejected, and billing teams experienced a reduced administrative workload due to fewer corrections and resubmissions. The overall revenue cycle became more efficient, with fewer disruptions and stronger compliance with payer requirements.