Claims & Contract Management
Improve accuracy and timeliness of net receivables
At the beginning of the year, the healthcare industry moved away from Medicare identifiers based on Social Security Numbers (SSNs), in favor of more secure Medicare Beneficiary Identifiers (MBIs). As with any large-scale change program, the shift was unlikely to be completely clear sailing. But with the coronavirus pandemic landing shortly after the 21-month transition period was due to conclude, the switchover has been rougher than expected. Impacted Care Care providers are discovering newly eligible Medicare beneficiaries who haven’t yet received their card, while existing beneficiaries have misplaced theirs. Without a valid MBI number, patients risk delayed access to care, while the admin process to sort it out can be stressful, especially for already-vulnerable senior populations. For providers, the extra work and delayed reimbursements are particularly unwelcome when COVID-19 is already putting pressure on services and squeezing revenue. Unprecedented intake conditions where staff and patients are trying to limit face-to-face contact makes it difficult to complete the usual coverage checks. As a result, providers are missing revenue opportunities they cannot afford, while incurring additional downstream costs when collections are delayed. Experian Health clients are optimizing Coverage Discovery to speed things up. Case study: how one healthcare provider is finding missing Medicare coverage faster For example, the southeast division of a national health care system, with 1700+ beds and $1.6B in revenue, needed better ways to find MBIs when Health Insurance Claim Numbers (HICNs) were phased out. Assisting Medicare patients with tracking down their MBIs was time-consuming and error-prone. They came to Experian Health to find a more efficient way to check Medicare coverage. Jason Considine, Experian Health’s Senior Vice President for Patient Collections and Engagement, says: “We knew we could help because we already had Medicare coverage history through our historical repository. As a test, we were given a control set of known Medicare patients without MBIs, and were charged with finding those patients’ MBIs and Medicare coverage.” Experian Health’s Coverage Discovery tool was used to batch-process the control set. This took less than a day, as the tool scans more than one million accounts daily, using historical and demographic data, synthesized with multiple proprietary data sources, to find unknown or forgotten coverage. In this case, the resulting data was collated via batch files, but could be integrated with other coverage and collections tools, such as eCareNext, which automates the more repetitive and hands-on pre-registration tasks. Coverage Discovery found 60% of the Medicare coverages with MBIs, plus additional coverages. This enabled the provider to file claims that would otherwise have been nearly impossible and very time consuming. The provider’s next steps will be to integrate Coverage Discovery with eCareNext, and roll it out to more of sites in the system. Could Coverage Discovery help your organization find missing MBIs? Capturing better insights into productivity, financial results, and staff workflows is always valuable. But in the current crisis, tool that maximize reimbursement and automating the tasks that take up staff time is essential. Through our historical data repository, Experian Health’s Coverage Discovery already contains many patient MBIs – and it’s continually updated. We can help you search for Medicare coverage and make sure your clients find their MBIs, easing pressure off your revenue cycle management teams during this extremely challenging time. Request a review of Coverage Discovery and improve your coverage and collections processes.
For many of the 36 million Americans who have registered for unemployment benefits during the coronavirus outbreak, losing their job means losing their health insurance. Options for the newly-unemployed are limited yet complicated: while the federal government has declined to reopen enrollment under the Affordable Care Act, several states are supporting those without coverage by opening emergency enrollment periods for state-based health exchanges. Those that can afford it may extend their existing employer plan through COBRA, while those that can’t may apply for Medicaid. But unfortunately, millions will be left without coverage. Now, with these changes happening in both large quantities and at rapid speed, the process for checking a patient’s coverage status is more complex, time-consuming and susceptible to errors than in normal circumstances. Further errors may appear as patients are forced to switch care teams, leading to disjointed care and incomplete, inaccurate or duplicate health records. It’s a huge administrative and financial burden for providers, who must keep pace with changes to the health insurance landscape or risk a surge in denied claims as a result of patient misidentification. How should they guard against patient identity errors and minimize revenue loss in the wake of COVID-19? How to prevent mismatched patient records and avoidable claims denials A 2018 survey found a third of denied healthcare claims were caused by patient identity errors, costing hospitals an average of $1.5 million. We may see this figure creep up following COVID-19, unless providers move quickly to implement robust identity proofing and patient matching processes. Providers looking to do this should consider prioritizing the following three areas: Eliminate errors during patient registration Up to half of denied claims occur earlier in the revenue cycle, which is also when most duplicate medical records are created. Improving identity proofing during patient scheduling and registration is a logical place to focus, to ensure records are accurate from the start. This should include proactively checking for active coverage as early as possible. Using a Coverage Discovery tool that automatically finds available coverage will help avoid bad debt write-offs and give patients peace of mind. Essentia Health’s Patient Access team were able to find 67% coverage pre-service, for patient accounts that were previously considered self-pay or uninsured. Automate identity matching throughout the revenue cycle When patient records are incomplete, duplicated or overlaid with part of someone else’s record, denied claims become an accepted cost – but they’re often avoidable. Instead of time-consuming and error-prone manual checks, providers should consider using automated identity management software to ensure patient records are accurate and complete. Data-driven matching technology supported by a Universal Patient Identifier allows a single view of each patient to be shared safely and securely across multiple healthcare services. There’s no need for tedious reconciliation work and providers can be confident they’re submitting clean claims each time. Improve identity management protocols for telehealth and mobile services More patients turning to telehealth services and patient portals to minimize face-to-face contact, putting pressure on providers to solve the patient matching problem. And with payers expanding coding for reimbursements for telehealth and remote services, there’s an added imperative to make sure patient information is accurate in order to minimize the risk of claims denials. Victoria Dames, Senior Product Director at Experian Health, says portal access has increased by roughly 40% since the start of the coronavirus outbreak, and explains that the rise in telehealth and mobile services means identity proofing must be a priority: “If you don’t already have identity proofing and automated solutions for patient matching in place, you’ll have duplicate records. We don’t want that – it’s important to have one view of the patient. But we need to move quickly. Automating for identity proofing eliminates the risk of human error and it’s faster too, which is crucial right now. We know many providers want to get their identity management and claims management systems optimized quickly, so we have a team set up to help.” Using the right technology to verify patient identities and analyze claims, avoidable denials resulting from missing or incorrect information can be caught sooner. Contact us to find out how we can help your organization manage patient identities to eliminate costly claims denials during and after COVID-19.
There’s a phenomenon in online product reviews where the customer seems to love their purchase, yet gives it only one or two stars. Why do they do this? Poor customer service: the item was delivered late, questions went unanswered, or payment processing was disorganized. When the consumer experience falls below expectations, the brand suffers – no matter how good the product. The same thing happens in healthcare. The clinical care may be outstanding, but if the patient finds billing frustrating or confusing, it’s those feelings they’ll associate with the overall experience. Many healthcare providers suffer reputational damage because the patient financial experience fails to match high quality clinical care. This is especially true for patients who find themselves without coverage and in need of financial assistance, which is often an extremely stressful process. And with unemployment levels soaring as a result of the coronavirus pandemic, it’s likely more Americans will need to explore eligibility for charitable support. Finding smarter, speedier and scalable ways to check charity care eligibility is even more important. Using automation for faster charity care checks Automation may be the answer. With a system that runs checks quickly and easily against vast databases of up-to-the-minute records, providers can discover a patient’s propensity to pay before treatment is even carried out. Clarity from the outset ensures the patient is put on the right payment pathway and lays the groundwork for a positive patient financial experience. Caye Mauney, Patient Access Director for Palo Pinto General Hospital, tells us how her organization used data-driven financial clearance checks to improve the patient financial experience and reduce bad debt: Speeding up checks for earlier eligibility decisions Prior to using automation, Palo Pinto General used a time-consuming and labor-intensive paper-based process to determine a patient’s eligibility for charity assistance. But with automated screening prior to or at the point of service, the hospital can now verify whether patients qualify for charitable assistance within three seconds, and quickly connect them to the right program. For those with a self-pay amount, a Healthcare Financial Risk Score can be calculated using historical payments information and credit history, to help determine the optimal payment plan. Mauney says: “All the information we need is now at our fingertips. The patient no longer needs to bring in check stubs or go back to a former employer to ask for information. It’s been a game changer.” Creating a personalized patient experience At Palo Pinto, staff wanted to make sure that patients were taken care of not only medically, but financially too. Just as each patient needs medical care tailored to their individual needs, so too should their financial accounts be handled on a case by case basis. With custom payment plans based on an individual’s unique financial situation, the payment process can be transformed into an experience that patients no longer dread or avoid. Automated patient clearance checks draw on multiple sources of data and run analytics to quickly determine the best option for each patient. It can also generate scripts for patient advocates to use, to help patients navigate the process more easily. Palo Pinto reports improvements in patient satisfaction and trust as a result of uncomplicating the patient experience in this way. Reducing bad debt and increasing point-of-service collections Seamlessly connecting patients to the right financial assistance program allows patients to focus on their treatment, while feeling reassured that their financial obligations will be met. For providers, swift processing means decisions are made quickly, resulting in fewer accounts receivable delays and a lower risk of uncompensated care. At Palo Pinto General, quicker charity applications means more are being approved, and therefore not written off as bad debt – ultimately helping their bottom line. Discover how automating checks for charity care eligibility with Patient Financial Clearance can help your organization increase productivity, improve collections and boost patient satisfaction.
There is no doubt the healthcare industry has taken a financial beating as a result of COVID-19. But there is a glimmer of hope for providers. Several new announcements were recently made attached to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, specifically around reimbursements attached to COVID care for the uninsured. The financial stimulus, intended to stabilize hospital finances as providers face short-term revenue reductions due to the cessation of non-urgent procedures and the increased costs for personal protective equipment, has earmarked a portion of the $100B established for CARES to reimburse healthcare providers at Medicare rates for the treatment of uninsured COVID patients. The guidance does not indicate specifically how much money will be set aside to reimburse these claims. The big question? How long will the funds last and how quickly will providers act? With both unemployment, translating into more uninsured individuals, and COVID cases on the rise, the dollars could be exhausted quickly. A recent study by Kaiser estimates the total payments to hospitals for treating uninsured patients under the Trump administration policy would range from $13.9B to $41.8B. While Medicare payments are about half of what private insurers pay on average for the same diagnoses, estimates surrounding COVID care can be in excess of $50k for those severe cases where struggling patients spend weeks in the intensive care unit on a ventilator. Bottom line, it’s likely the funds will be distributed quickly, especially when factoring in unemployment skyrocketing. As of April 30, more than 30M Americans have filed jobless claims amid the coronavirus outbreak. The all-new portal opened on April 27 for sign-ups, and providers can begin submitting claims electronically on May 6. Healthcare providers who have conducted COVID-19 testing of uninsured individuals or provided treatment to uninsured individuals with a COVID-19 diagnosis on or after February 4, 2020 can request claims reimbursement through the program electronically and will be reimbursed at Medicare rates, subject to available funding. A complete list of FAQs regarding the CARES Act and reimbursements are accessible on the Health Resources & Services Administration website. But what other tips and considerations should providers contemplate as they attempt to get their fair share? Here are three actions to optimize a provider’s chances of claiming reimbursements for the uninsured. Automate the insurance check. Providers must attest that they have checked for healthcare coverage eligibility and confirm the patient is uninsured. If they fail to check, they may be denied. Providers must verify that the patient does not have coverage such as individual, employer-sponsored, Medicare or Medicaid coverage, or any other payer options that will reimburse for the COVID-19 testing and/or care of that patient. There are ways to automate this step, completing a second eligibility check to attest that the patients have no coverage before providers submit claims to the government. Scan for the social security number (SSN), if possible. While there may be instances where COVID patients entered a facility and were quickly admitted with no formal registration process, the CARES Act states an SSN and state of residence, or state identification/driver\'s license is needed to verify patient eligibility. If these pieces of information are not captured, providers need to attest that they have attempted to capture this information before submitting a claim. The patient may be long gone, but there are still ways to attempt to retrieve a patient’s SSN after they have exited the healthcare facility. Providers should know that claims submitted without an SSN and state of residence, or state identification/driver\'s license may take longer to verify for patient eligibility. Again, with the possibility that these funds could quickly be exhausted, it is in the provider’s best interest to submit claims that are as clean and validated as possible. Act fast. Recall the Small Business Administration\'s Paycheck Protection Program (PPP) — a coronavirus relief fund for small businesses that was also established under CARES? The $350B allocated by the bill was quickly depleted in days. While these funds were going to individuals in entirely different industries, there is no concrete projections on how long healthcare providers can expect the $1B fund to cover reimbursements for the uninsured. So, providers need to act now, and fast, by tapping into automation and auditing solutions that will optimize their chances of securing their fair share.
Recovering underpayments from commercial insurers costs the healthcare industry billions every year. When payments come up short against what the provider expects, it’s not just the missing revenue that puts a dent in the bottom line – the staff time spent on reprocessing bills takes an extra bite out of the organization’s margins. Underpayments can be attributed to confusion around changing payer policies, inadequate claims data and simple human error. But when providers are focused on creating the best possible patient experience, keeping track of payer behavior is a task that’s easily crowded out. Unfortunately, failing to spot underpayments or keep tabs on those policy changes could lead to bigger revenue loss further down the line, in the time-suck that is collections recovery. From the payer’s perspective, it can be hard to understand why providers don’t just fill out claims according to the agreed rules. For providers, those rules seem to be in constant flux and different for each insurer. Ultimately, it’s a lack of communication that’s at the heart of the problem. Clean claims are only possible when payers tell providers exactly what they need, and providers have the systems in place to deliver that and check that payers are themselves following those rules. Within the industry, we already measure so many aspects of the revenue cycle, but are we paying enough attention to the payer-provider relationship? Is communication the missing metric? Three essential ingredients for a healthy payer-provider relationship Managing payer contracts can often be time consuming, complex and costly. Many healthcare providers are focusing on three strategies to help build better relationships with their payers, to take the stress out of this process and ensure they get reimbursed quickly and fully: Better communication. When you’re clear about what your payers need, you can make sure all your staff and systems are set up to deliver that. It’s impossible to fix the sticking points in your claims processing if you don’t know where they are. With a method to support better communication with payers, you can negotiate contracts that better suit both parties, keep track of changes to payer policies and move quickly when payers aren’t holding up their end of the bargain. You’ll know when a payer has made a payment at an out-of-network rate or reverted to rates in a previous policy and you’ll have the data your payer needs for a quicker recovery process. Two-way accountability. One way to build a better relationship with your payers is to hold each other accountable. Providers need to have systems in place to be able to hold payers to account for underpayments, but also to hold themselves to account for under billing. With a robust contract management tool, you can monitor payer compliance with contract terms and clarify what’s expected on your side to ensure you submit clean claims every time. Efficient processes: When the payer landscape is constantly changing, you need to have solid workflows to manage your claims processes as efficiently as possible. Automation and software solutions can help you minimize staff time spent manually checking payer policies, as well as generating the data you need to challenge underpayments. With a dashboard showing you real time claims data all in one place, your team will be able to identify, discuss and resolve queries with payers much more quickly than with disparate manual systems. How better payer monitoring saved one practice group $3.5 million in a single year In 2007, UCLA Health System Faculty Practice Group (UCLA FPG) saw $4 million go uncollected, largely down to difficulties tracking payer contracts. As the volume of payer contracts grew, it was harder to catch underpayments and manage the recovery process. Measha Ford, Director of Revenue Integrity at UCLA FPG says: “Before using Contract Manager, we didn’t have a method in place to track under and overpayments so there was a lot of lost revenue.” Without an efficient system in place, it was extremely challenging to manage collections data, monitor payer performance and spot when claims were being paid at out-of-network rates. This put UCLA FPG in a tough position to try to negotiate the best possible contracts with payers. By implementing an automated system, UCLA FPG could keep a closer check on payer contracts, eventually sustaining a recovery rate of 80% and recouping $3.5 million in one fiscal year. The data collected has not only helped to build a more predictable revenue cycle, but also supports more strategic decision-making when modeling new and amended contracts. And for Measha and her team, being armed with up to date, reliable data makes managing the relationships with payers so much easier, saving them time and effort that can be better used elsewhere. Find out more about how Experian Health Contract Manager can help you create friction-free interactions with your payers.
It’s almost time to say goodbye to Health Insurance Claim Numbers (HICNS). Earlier this year, the Centers for Medicare and Medicaid Services (CMS) began the process of removing HICNs from Medicare cards, replacing them with a new Medicare Beneficiary Identifier (MBI). From January 1, 2020, CMS will only consider claims bearing the patient’s MBI number. With 150 million numbers issued to active and archived beneficiaries, the scale of the change could have a major impact on providers and their billing processes. Here, we look at how healthcare organizations can ensure they’re as prepared as possible. Why change to a Medicare Beneficiary Identifier? The shift to MBIs is an effort to protect patient information and address the vulnerabilities that come with relying on Social Security Numbers (SSN) to verify patient identities. HICNs are tied to an individual’s (or their spouse’s) SSN, which, according to cybersecurity experts, is an increasingly lucrative route to stealing someone’s identity. In 2018, over 1200 data breaches were reported, with over 400 million records exposed. Of these, SSNs were the most commonly exposed piece of data across all industries, with the exception of the healthcare and medical sector (which is affected nevertheless, given the industry’s widespread use of SSNs). Once a fraudster has their hands on someone’s SSN, it’s all too easy for them to create a fake identity and wreak havoc on that person’s life. What’s more, criminals can currently use SSNs in this way to access medical services or drugs under someone else’s name. Medical fraud is thought to cost between $80 and $230 billion annually in the U.S. If SSNs are no longer a means of confirming medical identities, the emotional and financial costs of medical fraud can be avoided. So, while plans for funding a national patient identifier may have been stalled for now, the MBI represents a significant step forward to protect patients from identity theft, keeping their information safe and reduce the likelihood of medical fraud. What does the transition to MBIs mean for your organization? Like the implementation of ICD-10, this is a huge transition for CMS and providers alike. Most providers are already using both numbers to manage patient claims, with 76% of fee-for-service claims submitted using the MBI for the week ending July 5, 2019. You can continue using the HICN for Medicare transactions such as billing, confirming eligibility status and checking claim status until the end of this year, but after that, Medicare will deny claims that don’t include the MBI. There are some exceptions, but the general rule is that claims must be submitted with the MBI, no matter when the service was provided. How should providers prepare for the MBI transition? The lower your denial rate, the healthier your revenue cycle will be. To avoid unnecessary denials as a result of the MBI transition, providers should consider the following strategies to ensure a smooth transition: Check systems and procedures Your software systems, automated processes and patient-facing procedures should already have been adapted to accept MBIs. Ensure your staff have processes in place to check and add new MBIs for existing and current Medicare patients. Remember, you’ll need to continue tracking HICNs alongside the new MBIs for the lifecycle of current claims. Appeals will use whichever identifier was used to submit the original claim. Reach out to existing patients The MBI won’t affect Medicare benefits, but recipients should all have received their new number and will need to use it to access services. Make sure existing patients are aware of the change and encourage members to update their details via their patient portal. Remind them to bring their new Medicare card to future appointments. Obtain an MBI for new patients When new patients register with you, ask for the new MBI. If they don’t have it, you should be able to look it up using your Medicare Administrative Contractor’s (MAC) web portal. Train staff so they know what to ask, how to use the MBI and how to answer patients’ questions. Alternatively, for about the past year, when a claim has been submitted to Medicare with a HICN, Medicare has returned the MBI on the remittance (835 file). This is something that can be used to create crosswalks. Optimize for cleaner claims One major effect of the change is that your existing method for carrying out Medicare scrubs, where SSNs could be used to check for Medicare eligibility based on demographic information, will no longer be possible. Consider a solution such as Claim Scrubber and Registration Quality Assurance to improve the accuracy of Medicare eligibility information. Encourage good data protection hygiene This is a chance to review your data protection practices. Consider whether there are additional steps you could take to safeguard your patient data and prevent medical theft. Are you ready? Experian Health’s Coverage Discovery tool already contains many patient MBIs through its historical repository, which grows every day. This historical repository contains a dataset of MBIs, which will allow us to continue searching for and presenting Medicare coverage to our clients when the transition period ends. Are you ready for this change to take place? Let’s schedule some time to review your coverage solutions and see if we can help improve your collection process.
Managing the revenue cycle draws in considerable resources for healthcare organizations, even when it’s working as planned. The American Medical Association puts direct transaction costs and inefficiencies associated with the “claims management revenue cycle” at around 25-30% of overall healthcare spending. But when errors are made and claims end up being denied, providers could end up missing out on as much as The total revenue leakage is probably higher, when you consider the opportunity cost of staff time spent sorting out denials. Among the most common reasons for denials are missing or incorrect billing information, non-covered charges for care, and absent authorizations. Thankfully, these are all issues that can be minimized with the right strategies and tools. By optimizing your revenue cycle from the outset so that claims are right first time, you can save hassle and expense later on. Here are 7 ways to proactively reduce claim denials in your health system. Figure out why claims are denied First things first. You need to understand where denials are occurring in your revenue cycle and why. You can determine the root cause of denials by analyzing data that’s already available to you alongside information on industry trends. A business intelligence tool can help you use advanced data analytics to find opportunities for improvement, and generate actionable insights that are focused on your specific KPIs. Once you know where the weak points are, you can get the ball rolling with solutions. Prioritize the big-impact fixes In all likelihood, most providers will have the opportunity to improve their claims process at several points in the revenue cycle. You can’t do everything at once, so identify the areas with the greatest potential impact on your hospital’s bottom line. Can denials be traced to a particular department, service line or physician? Has a certain payer changed their approach? Compare the cost of implementing processes to tighten up the weak points in the cycle with the amount of revenue likely to be recovered to ensure you get the biggest ROI for your efforts. Automate patient access for more accurate claims Up to half of denied claims occur early in the revenue cycle, during patient access and registration. Automating the patient access workflow with real-time data can create a more efficient and accurate process, linking front and back office staff with shared systems that minimize errors and staff time. Martin Luther King Community Hospital experienced these efficiencies first-hand, when they integrated eCare NEXT® within their existing Cerner® system. As a result, their registration process became more streamlined, enabling them to cut two to three minutes from more than half of their registrations. Ensure patient matching is as accurate as possible Incorrect patient matching is a major source of revenue leakage for many providers, with around a third of claims denied on the basis of inaccurate patient identification. When it costs $25 to rework a claim and around $1000 for each mismatched pair of records, that’s a lot of lost revenue. Resolve your patient identities with the most robust data sources, and not only will you reduce claim denials, you’ll also have a more complete picture of each patient, which in turn will give them a better patient experience. Streamline prior authorization checks A survey by the American Medical Association found that prior authorization checks created a substantial burden for providers, with physicians spending an average of nearly 15 hours per week dealing with related tasks. For patients, this process can lead to delayed or even abandoned treatment. Using automated software, you can check claims against payer rules for medical necessity, frequency, duplication and modifiers, so you can quickly spot any claims that may be denied and correct them before submission. Process claims effectively Once you’ve streamlined the front-end of the claims process, you should of course look for ways to improve efficiencies throughout the rest of the cycle and immediately before the claim is sent to the payer. In fact, providers are expected to invest up to , as the need to crack down on denials grows. Submitting claims in the correct format is a common and frustrating challenge. Since each payer has different requirements and formatting preferences for claim forms, edits should be customized. A revenue cycle service provider can help you build these custom edits and check each claim line by line, so you can submit with confidence and avoid having to redo them later. Monitor and analyze your revenue cycle Regular analysis is essential to consistently improve denial rates. By monitoring your internal processes across a range of metrics, you can gain a holistic view of the entire revenue cycle to see where there are further opportunities to optimize performance and prevent denials. When you have confidence in the freshness and accuracy of your data – including patient access data, payer performance information and patient matching – you can make confident decisions about exactly what needs to happen to improve your claims denials. Learn more about how leveraging data-driven insights to tighten up your claims management systems and take proactive steps to find lost revenue.
For many healthcare providers, claim denials are a frustrating cost of doing business. Each year, around 5-10% of medical billing claims are rejected (possibly more). With each claim costing around $25 to rework, providers lose billions in eroded revenue and productivity. Any revenue leakage is bad enough, but the shift towards value-based care means tighter revenue cycle management (RCM) is even more important. In an environment where everyone must do more with less, reducing claim denials could release vital revenue and staff time to create breathing space for quality improvement. The good news is that while only two-thirds of denials are recoverable, around 90% can be prevented. Using technology to access more reliable data, providers can eliminate avoidable denials resulting from missing or incorrect information, duplicate records, missed deadlines or unconfirmed eligibility. As they say, prevention is better than cure. Three ways to improve RCM and reduce claim denials Automated technology can help optimize all stages of the revenue cycle so claims are right the first time, saving headaches down the line. Three areas to focus on are: Patient access – using shared systems to connect front and back office staff more effectively Identity management – ensuring patient and payer information is accurate from the start Denials workflow – enabling more efficient follow-up and analysis, to resolve denials quickly and avoid repeats. Using technology to connect front and back office With 30-50% of denied claims occurring earlier in the revenue cycle, streamlining patient access and registration can eliminate a significant slice of expensive errors. Boys Town National Research Hospital used new technology to improve communication between front and back office teams, automating up to 80%of the pre-registration workflow. More accounts could be cleared upfront, so staff could focus on claims that were more likely to cause issues. After just one year of using the automated software, all manual work was eliminated and eligibility denials dropped 20%. Clean data in, clean data out Automating rote tasks isn\'t the only way to ramp up productivity at the front end of the revenue cycle. Around a third of all denied claims are associated with inaccurate patient identification. According to a survey from Black Book Research, this costs the average hospital $1.5 million and the U.S. healthcare system over $6 billion annually. \"As data sharing grows and challenges in connectivity are tackled, resolving patient record matching issues has become more urgent and complex,\" said Doug Brown, Managing Partner of Black Book Research. When a minor error such as a wrong insurance address can wreak such havoc, it makes sense to use demographic data to guarantee accurate patient details. Duplication is another major issue. On average, as many as 12% of healthcare records are duplicates, mostly due to misidentification during registration. Reconciling these records costs around $1,000 per pair, amounting to millions of wasted dollars annually. This isn\'t just an administrative or financial concern. Misidentification leads to patient distrust, pharmaceutical abuses, and redundant treatment, which risk patient safety and drive up costs for patients and providers. Healthcare staff need to feel confident that the patient is who they say they are, with a single, complete record. Using technology that can apply an algorithm of sophisticated matching methodologies can clean up patient data and eliminate duplicate and inaccurate records. Resolve denials quickly and learn from mistakes Finally, when denials do occur, they must be managed efficiently. Schneck Medical Center upgraded its denial management process, giving staff real-time insight into how claims are progressing. Automated software identifies which claims need following up, so back office staff can now manage claims without manual review. McKenzie Smith, Director of Patient Financial Services said: \"No longer are we waiting 30 to 45 days to review denials. We can review them on the day of [submitting] if we choose to.” Insights from whole system data reporting and analytics give front office staff immediate feedback to spot issues that can be avoided in future, looping back to those preventive measures. What’s more, working with a claim scrubber that allows custom pre-billing edits will further ramp up the likelihood of achieving 100% clean claims. However, this only works if your denials management system can analyze the root causes of denials and incorporate unclear or unpublished payer rules. Prevent, manage and analyze your RCM system to reduce claim denials This is an exciting time to be in healthcare finance. Technology offers many opportunities to radically reduce revenue loss, but few providers are using it to maximum effect. Healthcare providers should shift from reactive to proactive claim denial management, looking at the whole RCM process. Ideally, this means using technology to prevent denials in the first place, improving processes for managing denials when they do occur, and then using a robust analytics platform to understand what went wrong so it can be avoided in future. But data management tools are only as good as the data itself. As in all aspects of healthcare, quality matters.
A recent Black Book survey of more than 500 healthcare networks revealed that hospitals in the U.S. have been painstakingly slow in adopting healthcare revenue cycle management (RCM) solutions. At the start of 2018, nearly 26 percent of hospitals had no viable solution in place, and 82 percent of them planned to make value-based reimbursement decisions without one. For most hospitals, one of the biggest challenges in implementing RCM solutions is finding talent with the right skill set to handle RCM software difficulties. It’s a problem that even the largest healthcare delivery networks face and one that UCLA Health hospitals had to overcome. UCLA Health System Faculty Practice Group (UCLA FPG) employs more than 2,500 physicians with more than 220 primary and specialty practices. Keeping up with payer contracts In 2007, more than $4 million in revenue went uncollected at UCLA FPG. The group’s RCM pain points were typical of those in the industry. For example, the group was unable to keep track of over- and underpayments, which made it difficult to adhere to payer contracts. It was also difficult to manage appeals and track recovery as the volume of payer contracts grew and became increasingly more complex. The difficulty UCLA FPG had in gathering and exporting information, in addition to the complexity and volume of contracts, left it with little negotiating power when dealing with payers. UCLA FPG\'s numbers continued to fluctuate until implementing Epic alongside Experian Health\'s Contract Manager. Using this web-based solution, UCLA FPG has been able to automate and improve its revenue cycle due to the solution’s ability to continually monitor and update every payer contract. This has also helped the healthcare group stay compliant with all payer agreements by making it possible to catch errors faster. Director of Revenue Integrity Measha Ford states: “We are able to catch Medicare overpayments faster with the contract management system. We recently integrated all our Medicare contracts into the system to have a lower risk of compliance issues since we only have 60 days to refund Medicare back once we identify an overpayment. Having this system, having that ability to load the contracts into the system to catch these potential risks, is very helpful.” The UCLA network now has fewer administrative write-offs every year, faster AR collections, and reduced denials. Experian Health\'s team maintains contract terms, fee schedules, and payment policies and makes sure every claim processed follows UCLA\'s contract terms. Online dashboards and reports help monitor reimbursement and reduce payment discrepancies through interactive graphs that expose source claim data and practice management system-specific data attributes. Analyzing contracts before signing up In addition to tracking and managing contracts, the group also knows exactly how a new contract or redefined contract terms will affect its bottom line. It has intel on real-world “what if” scenarios to provide insight into how various contract terms affect cash flow for the precise mix of services the group provides. It\'s also able to avoid unfavorable contract terms, as they are easily spotted through analysis. Are health plans complying with your contract terms? Learn more about how we can help you find lost revenue with data-driven insight.
