Wuscott Automated Key RCM Bottlenecks for Southwest Labs
May 22, 2025
Key Takeaways:
• Front-end automation (like insurance discovery) delivers fast ROI
• Denial resolution bots require experimentation, but save time, employee burnout, and can yield significant cash from either immediate appeals or recovering claims destined for accounts receivable
• Automation is not scalable, it is very specific requiring deep knowledge, actionable data, and valued partner
• The combination of analytics + automation = compounding results
Background:
In today’s healthcare landscape, laboratories are navigating a volatile billing environment: rapidly shifting payer policies, complex coverage requirements, and denials that chip away at revenue with every missed opportunity.
Southwest Labs (SWL), a high-volume diagnostic laboratory serving rural communities in New Mexico and the surrounding region, found itself facing these exact issues. Despite growing accession volumes and a robust test menu, revenue wasn’t keeping pace. Denials for missing information, unenrolled ordering providers, and eligibility gaps created friction at every stage of the revenue cycle.
This case study explores how Wuscott deployed targeted automation to streamline eligibility checks, reduce denial write-offs, and accelerate payment—without disrupting the lab’s clinical or operational workflows.
Use Case #1: Insurance Discovery
SWL was experiencing a 7.2% ineligible/no-insurance rate. Many of these claims were being written off due to missing provider information and external insurance discovery vendors were expensive, costing more than $2 per patient.
The Solution:
In New Mexico, 40% of patients have Medicaid which created an opportunity for a first discovery attempt to find insurance via the Medicaid portal, which is free. Therefore, Wuscott built and deployed a customized insurance discovery bot using Microsoft Power Automate.
The bot leveraged patient demographic data to check NM Medicaid eligibility via the state portal, flagging patients with active coverage that was missed during intake. If the patient had Medicaid, we immediately fixed the claim and sent it out.
The Impact:
• Reduced eligibility-related rejections
• Savings of $1,996 in external vendor costs (insurance discovery)
• Built in just 4.5 days, delivering immediate ROI at over $300,000 for 2,439 accessions
Use Case #2: Infectious Disease Denials — Navigating Payer Policy Ambiguity
SWL’s infectious disease testing panels were experiencing denials from a specific payer, with two CPT codes either underpaid or outright denied:
• 87798: Paid $0
• 87632: Paid $148.90 (vs. expected amount)
The denial reason: missing or invalid information. But what was the payer looking for?
The Solution:
Wuscott implemented an experimental appeal strategy, submitting variations of documentation to identify the exact requirements to secure payment. Once identified, we deployed a bot to manage both retrospective and prospective appeals.
The Impact:
• Enabled faster turnaround on appeals
• Saved approximately 0.3 FTE in manual effort
• Yielded over $270,000 in reversed denials for 934 claims
Use Case #3: Toxicology Denials — Resolving Documentation Requirements
One major payer (BCBSNM) was denying toxicology claims based on missing documentation. However, the policy requirements were broad and inconsistently enforced. Manual appeals were time-intensive and frequently unsuccessful.
The Solution:
Wuscott launched a structured testing initiative, trialing different combinations of medical records to isolate the payer’s true requirements. This included:
• Provider-signed requisitions
• Complete result reports signed by the physician
• Documentation of patient identity, sample collection, and location
Once the winning formula was found, we automated the appeal process end-to-end.
The Impact:
• 51% acceptance rate across automated appeals
• Generated $47.50 in revenue per accession
• Each appeal took ~8 minutes of bot runtime, allowing staff to focus elsewhere
Lessons Learned: Scalability, Trade-offs, and Smart Automation
Not all automation is plug-and-play. Each solution required:
• Careful data analysis to isolate the root issue
• Small-scale testing to prove efficacy
• Ongoing bot management to handle login issues, portal timeouts, and payer quirks
• To date, the bot has appealed 2,508 denials and derived nearly $120,000 in payments
But the upside? Once proven, these bots ran 24/7, never missing a step.
Conclusion: From Friction to Flow
Wuscott helped Southwest Labs transform billing bottlenecks into scalable automation workflows. In doing so, we didn’t just recover revenue, we reduced friction, freed up staff, and created a new standard for what labs can expect from their RCM.
Each automation requires experimentation, curation, and management, so if you’re still treating denials like a dead end, it might be time to call for help.
Reach out to us for a risk-free minimal cost assessment.
Key Takeaways:
• Front-end automation (like insurance discovery) delivers fast ROI
• Denial resolution bots require experimentation, but save time, employee burnout, and can yield significant cash from either immediate appeals or recovering claims destined for accounts receivable
• Automation is not scalable, it is very specific requiring deep knowledge, actionable data, and valued partner
• The combination of analytics + automation = compounding results
Background:
In today’s healthcare landscape, laboratories are navigating a volatile billing environment: rapidly shifting payer policies, complex coverage requirements, and denials that chip away at revenue with every missed opportunity.
Southwest Labs (SWL), a high-volume diagnostic laboratory serving rural communities in New Mexico and the surrounding region, found itself facing these exact issues. Despite growing accession volumes and a robust test menu, revenue wasn’t keeping pace. Denials for missing information, unenrolled ordering providers, and eligibility gaps created friction at every stage of the revenue cycle.
This case study explores how Wuscott deployed targeted automation to streamline eligibility checks, reduce denial write-offs, and accelerate payment—without disrupting the lab’s clinical or operational workflows.
Use Case #1: Insurance Discovery
SWL was experiencing a 7.2% ineligible/no-insurance rate. Many of these claims were being written off due to missing provider information and external insurance discovery vendors were expensive, costing more than $2 per patient.
The Solution:
In New Mexico, 40% of patients have Medicaid which created an opportunity for a first discovery attempt to find insurance via the Medicaid portal, which is free. Therefore, Wuscott built and deployed a customized insurance discovery bot using Microsoft Power Automate.
The bot leveraged patient demographic data to check NM Medicaid eligibility via the state portal, flagging patients with active coverage that was missed during intake. If the patient had Medicaid, we immediately fixed the claim and sent it out.
The Impact:
• Reduced eligibility-related rejections
• Savings of $1,996 in external vendor costs (insurance discovery)
• Built in just 4.5 days, delivering immediate ROI at over $300,000 for 2,439 accessions
Use Case #2: Infectious Disease Denials — Navigating Payer Policy Ambiguity
SWL’s infectious disease testing panels were experiencing denials from a specific payer, with two CPT codes either underpaid or outright denied:
• 87798: Paid $0
• 87632: Paid $148.90 (vs. expected amount)
The denial reason: missing or invalid information. But what was the payer looking for?
The Solution:
Wuscott implemented an experimental appeal strategy, submitting variations of documentation to identify the exact requirements to secure payment. Once identified, we deployed a bot to manage both retrospective and prospective appeals.
The Impact:
• Enabled faster turnaround on appeals
• Saved approximately 0.3 FTE in manual effort
• Yielded over $270,000 in reversed denials for 934 claims
Use Case #3: Toxicology Denials — Resolving Documentation Requirements
One major payer (BCBSNM) was denying toxicology claims based on missing documentation. However, the policy requirements were broad and inconsistently enforced. Manual appeals were time-intensive and frequently unsuccessful.
The Solution:
Wuscott launched a structured testing initiative, trialing different combinations of medical records to isolate the payer’s true requirements. This included:
• Provider-signed requisitions
• Complete result reports signed by the physician
• Documentation of patient identity, sample collection, and location
Once the winning formula was found, we automated the appeal process end-to-end.
The Impact:
• 51% acceptance rate across automated appeals
• Generated $47.50 in revenue per accession
• Each appeal took ~8 minutes of bot runtime, allowing staff to focus elsewhere
Lessons Learned: Scalability, Trade-offs, and Smart Automation
Not all automation is plug-and-play. Each solution required:
• Careful data analysis to isolate the root issue
• Small-scale testing to prove efficacy
• Ongoing bot management to handle login issues, portal timeouts, and payer quirks
• To date, the bot has appealed 2,508 denials and derived nearly $120,000 in payments
But the upside? Once proven, these bots ran 24/7, never missing a step.
Conclusion: From Friction to Flow
Wuscott helped Southwest Labs transform billing bottlenecks into scalable automation workflows. In doing so, we didn’t just recover revenue, we reduced friction, freed up staff, and created a new standard for what labs can expect from their RCM.
Each automation requires experimentation, curation, and management, so if you’re still treating denials like a dead end, it might be time to call for help.