Strengthening international revenue capture in high-volume emergency department settings

The background

A large multi-state nonprofit US health system with over 50 hospital campuses, 10,000 plus licensed beds, and millions of annual patient encounters partnered with Sunbelt Health Partners to address persistent challenges related to international patients presenting through the emergency department (ED).

Key challenges

Front-end identification gaps

• No standardised international screening during ED registration

• Inconsistent capture of international contact information or travel policy details

• International patients misclassified as domestic self-pay.

EMR workflow limitations

• No real-time international tagging at arrival

• International teams engaged only after admission

• Work queues triggered too late in the revenue cycle.

International payer complexity

• Non-contracted payers seeking contracted rates

• ‘Silent PPO’ repricing without transparency

• Variable medical necessity definitions

• Longer adjudication cycles

• Policy exclusions including pre-existing conditions. Financial impact

• Yield plateaued at ~40% of charges

• Days-to-bill frequently delayed by 30- plus days

• Accounts receivable (AR) ageing

extended beyond standard benchmarks.

Solutions

Operational front-end workflow optimisation

• Defined clear ‘international; identification criteria separate from LEP

• Hardwired ED intake questions and documentation into registration workflows

• Implemented real-time electronic medical record (EMR) tagging and routing logic

• Established clean handoff between provider and partner. Eligibility and coverage research

• Real-time verification of benefits and exclusions

• Coverage validation for unknown or employer-sponsored plans

• Early identification of medical necessity standards and policy limitations. Payer engagement and escalation

• Benchmark yield targets by payer cohort

• Formal escalation playbook for repricing and denials

• Legal and clinical review for contested reimbursement. Performance reporting and governance

• Weekly AR and yield scorecards

• Monthly performance reviews

• Root-cause analysis of denials

• Shared accountability model.

Implementation

Implementation began in early 2024 and was phased across high-volume ED facilities.

The rollout included:

Training

• ED registrars and access teams trained to capture international indicators at intake

EMR configuration

• International flags embedded at registration; routing rules built into work queues Workflow redesign • Defined provider versus partner responsibilities for claim release and follow-up

Workflow redesign

• Defined provider versus partner responsibilities for claim release and follow-up

Governance

• Monthly review cadence focused on yield, cycle time, and payer performance

Additional implementation activities

• Training: emergency room and registration teams were trained on identifying international patients and capturing coverage details at intake

• System integration: daily EMR extracts were used to ingest registration and claim-level data

• Contract review: Sunbelt’s legal team audited existing payer arrangements and began pursuing aged receivables with contractual leverage.

Key metrics

• Reduction in cycle time

• From 90-plus days to ~45 days on average

• Yield improvement

• 16-plus percentage point increase from pre- to post-implementation.

Summary

This partnership demonstrates how an international claims centre of excellence can transform revenue performance. The Sunbelt model is simple, contingencysuccess-based, and built to integrate.