Case Study
How San Juan Regional Medical Center Built a Billing Compliance Program From Scratch and Audited $1.59M in Charges in a Year
Before MDaudit, San Juan Regional Medical Center had no billing compliance program at all, no risk-based auditing, and no reliable way to even pull a report from its EHR when a PEPPER report flagged a concern. As a rural hospital with an 86% Medicare, Medicaid, and uninsured payer mix, every dollar protected mattered more than most.
Background Summary
Rural hospital builds a billing compliance program from scratch after years with no risk-based auditing.
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See how San Juan Regional Medical Center built a billing compliance program from scratch and audited $1.59M in charges in a year.
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The Customer Profile
San Juan Regional Medical Center (SJRMC) is a nearly 200-bed Level III Trauma Center. With 19 specialty clinics, this rural, community-owned nonprofit hospital serves the Four Corners region of New Mexico, Arizona, Utah, and Colorado. Founded in 1910 by two physicians who saw a need for quality healthcare in their community, SJRMC actively participates in the 340B Program to keep medication and care accessible across the communities it serves.
The Solution
MDaudit Billing Risks leverages charge data regularly ingested from claims, with pre-built analytics and peer benchmarking, to identify healthcare billing compliance insights.
- Streamlined audit workflows caught a locum interventional cardiologist who had zero billable procedures charged in their first 60 days due to charting errors, an issue that could have gone undetected indefinitely
- A routine audit uncovered years of Botox waste being billed incorrectly (one unit per injection instead of actual micrograms wasted), dating back to a 2019 EHR go-live
- Drill-down dashboards and reports help the team detect billing and coding anomalies and identify root causes, not just symptoms
The Results
- Completed 1,000 audit cases and audited $1.59M in charges over 12 months
- Surfaced 1,660 audit case findings, including $182K in non-agree findings
- Caught individual issues, like a locum’s zero-billed procedures and years of mis-billed Botox waste, that had gone undetected for months or years
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