Some of our team members has been collaborating with a dental tech startup that plans to disrupt the way revenue cycle management is done in the dental industry.

What is RCM (Revenue Cycle Management)?

Revenue Cycle Management (RCM) in the field of dentistry involves overseeing the financial aspects of patient care throughout the entire lifecycle of a patient account. This comprehensive process includes various key components that contribute to the efficient management of a dental practice's finances. Verifying patients' insurance coverage helps ensure that the dental office possesses accurate information about the patient's benefits and coverage.

This is essential for determining the patient's financial responsibility and avoiding claim denials. Properly documenting treatment plans and procedures is crucial, including recording the procedures performed, diagnosis codes, and any other relevant information.

After performing procedures, the practice submits a claim to a clearing house so that the insurance companies can reimburse. Timely and accurate claim submission is essential to ensure the practice receives payment for the services provided.

The Problem: Dentists lose 30%+ of revenue due to denial from claim errors

On top of clinical errors, something as simple as a missing apostrophe in someone’s last name or a wrong date format can stop a dental office from getting paid by the insurance company for a particular procedure. In other cases, missing clinical information causes a claim denial.

Due to the broken process in RCM, dentists lose billions of dollars over the lifetime of their practices. Keeping track of this remains a challenge as well.

Many of these dental practices use different PMS (patient management systems) that hold the source of truth about their patients and practice performance. Some dentists are not even using the software at all to rectify their claims

Solution

A “Not Ugly” User Interface

Material UI is a frontend library that I’ve been using for years that allows me to create highly customizable user interfaces for my clients’ software that are 100% responsive and work in all browsers. Complex components, new features, and changing requirements became less of an issue due to the robust features of Material UI and React’s MVC architecture.

Cost Effective Software Architecture

This application started as a proof of concept. Later turned into an official MVP due to some positive feedback from stakeholders and practice managers.
We choses the 3 tier architecture with each layer being on its own separate machine to reduce our attack surface. Application gateway was used to safely route the traffic to the backed server without exposing it to the public internet.

Azure Entra AD (formerly called Active Directory) allowed use to alleviate the responsibility of building an authentication from scratch. Users were allowed exclusive access to the application based on their domain and role assignments listed in the SQL server

Features

Claims Queue

Easy-to-understand claims queue table organized based on dollar value and aging. Analysts are first shown claims with most urgency ( AI Alogorithm). Based on role assignments, they will be able to perform such actions such as archiving the claim or assigning it to a different analyst.

CARC Remedy Solutions

AI generated remedy steps by procedure line item.

Financial + Recovery Analytics

Live view of claim processing performance of multiple practices. View the amount of collections and denials by location, subscriber, and practice group in various time frames. Practice managers are also given the ability to view the amount of paid and non-paid claim items for multiple locations at a time.

Plaid Bank Integration

Matching paid claims with ETF transfers to provide more clarity on revenue cycle management using Plaid API

Location Assignments

Assign analysts to various locations with different roles and permissions

System Design for High Availability, Security, and HIPAA Compliance

To ensure a secure and isolated network environment, we implemented a Virtual Private Cloud (VPC) with multiple subnets. The VPC allowed us to logically isolate different components of the system while providing secure communication between them.
Housing the backend components, such as databases and application servers in private subnets lowered our risk of a data breach due to the traffic being inaccessible to the public internet. This adds an extra layer of security to sensitive healthcare data. We used Azure’s Network L7 application load balancer to safely distribute public traffic from the internet to our frontend web server allowing users to login with their Azure enterprise accounts.
Ensuring system responsiveness and scalability, we employed auto-scaling groups for the Ubuntu VMs. This dynamic scaling approach allowed the system to automatically adjust the number of VM instances based on demand. We utilized custom VM images to maintain consistency and efficiency in scaling, ensuring that each newly launched VM adhered to security configurations and software versions.

Security Measures
HIPAA compliance was a top priority in our system design. We implemented several security measures, including:

SSL Encryption: Secure Sockets Layer (SSL) encryption was enforced to protect data in transit.
Data Normalization and Database Design: Proper data normalization and database design practices were followed to safeguard the integrity and confidentiality of patient information.

Result

The implemented system design has not only met the high availability and scalability requirements but has also ensured the confidentiality and integrity of patient data, aligning with the stringent standards of HIPAA compliance.

Along with the happy feedback, the startup raised another $1m in VC funding for the next phase of the project.

(TBD)
“Out of the 50+ locations, 78% have already seen a 37% increase in claims recovery/processing, recovering up to 89% of claims (up from the average of 60%). “