Claims & Contract Management

The repercussions of errors on the healthcare claims processing workflow can be major and wide-ranging. It slows the revenue cycle, interrupts cash flow, consumes staff hours, creates frustration for staff and patients, and, in the worst cases, sacrifices revenue. Errors are a perennial—maybe even inevitable—problem but understanding some common reasons behind these mistakes can help. Additionally, digital claims management tools can help you automate claims processing to reduce claims errors, submit cleaner claims, and get paid successfully. In June 2022, Experian Health surveyed 200 revenue cycle decision-makers to understand the current state of claims management. Watch the video to see the results: Any number of claim errors can lead to denials: incorrect medical coding, missing prior authorizations, clearinghouse issues and more. Here are 7 of the most common reasons for claim errors: 1. Claim errors can be caused by missing and inaccurate data “The number one denial issue most providers encounter is eligibility,” says Rob Stucker, Senior Vice President at Experian Health. “These issues begin upstream from the claims process during registration or pre-registration when the patient information that’s collected is either inaccurate or incomplete. It may be as simple as a patient giving their name as Rob instead of Robert, or the registration staff selecting Medicaid as the payer, instead of Medicaid Managed Care. If the eligibility information is even slightly off, the claim will come back as denied.” Collecting accurate demographic and insurance information up-front using digital patient intake tools opens the digital front door and can help eliminate errors during the healthcare claims management process. 2. Manual processes and disparate systems Wherever claims processes are not automated, human error and delays can set in. In addition to typical random glitches and mistakes, many healthcare providers struggle with disparate systems from multiple vendors, in which the front-end and back-end do not communicate seamlessly. Using a single vendor with solutions that manage the entire claims processing cycle can provide holistic help. ClaimSource manages eligibility validation by repurposing Experian eligibility transactions that providers have already run at registration and editing them against the claim.  This process allows providers to double-check the eligibility of the claim before it gets submitted, at no additional cost. In addition, it also does extensive claim editing, submissions, reconciliations, and reporting. This solution creates prioritized workflows and provides access to a national library of documented government and commercial payer edits, as well as custom edits, to meet individual provider needs. 3. Changes in payer requirements can cause claims errors “Providers tell us that a major pain point is constantly changing payer rules,” says Stucker. “Providers are confident that their claims are good, but the payers’ adjudication rules may have changed without prior notice.” The problem here is exponential: voluminous changes multiplied by a range of communication channels (or faulty communication) multiplied again by a proliferation of payers and policies. Keeping pace with these changes is difficult without partner support. “We continuously monitor hundreds of thousands of payer website pages each night for updates,” says Stucker. “When a change is flagged, an analyst looks at it and decides whether it should be added as an edit. We update our huge global library of edits on a weekly or even daily basis. These edits enable ClaimSource and our pre-837 editor, Claim Scrubber to automatically review claims for errors using the most recent payer updates. 4. Prior authorizations Pre-authorizations present challenges at many levels. 8 in 10 providers saw prior authorization requirements increase during 2021. Providers must track changing requirements, obtain authorizations prior to treatment or claims submission, and complete claims that meet complex requirements. When prior authorization requirements aren’t met, appealing a denial can be complicated at best, and many times prove to be irreversible. According to Medical Group Management Association data, a simple denial takes a seasoned biller two to eight minutes to work, but a complicated denial involving prior authorization requirements can take up to an hour to work, largely thanks to time spent on hold. Ensuring claims are completed as required in the first place using a pre-authorization tool, in combination with a claims editor that validates against pre-authorizations, saves valuable time and stress. 5. Short staffing and new trainees Staff hours and expertise are both in short supply, as many providers struggle to retain experienced staff and bring new hires up to speed. Having an automated process with built-in review and analytics can help ensure that claims are completed accurately and quickly. A Council for Affordable Quality Healthcare study found automated claims take 25% less time to process than manual claims, boosting productivity and freeing staff up for the more human-intensive aspects of their work. However, the key is “accurate and user-friendly” automation. A claims vendor should be keeping edits up to date, submitting claims timely and accurately to the correct payer, keep organizations informed on the claim’s status throughout the adjudication process, retrieve electronic remit files, link them to the correct claims, and establish a denial workflow to automatically show denials. This should all be done in an extremely easy to use user interface or directly back into Patient Accounting/Practice Management Systems. If vendors aren’t doing this, then staff will just be working harder instead of smarter. 6. Slow response and follow-through can lead to claim errors  Although delays themselves don’t necessarily cause errors, they can make resolution difficult and time-consuming. Time is always an issue for providers as claims must be submitted in specific time frames from the date of service. Therefore, getting the claim created, processed through a claims vendor and submitted to the correct payer must be done efficiently, or timely filing deadlines are missed.  The same is true for identifying and re-working denials. Denial backlogs quickly become overwhelming, increasing the odds of items slipping through the cracks or re-submission/appeal deadlines being missed. Automating status updates with enhanced claim status monitoring can relieve time-strapped staff of having to contact payers manually for the latest information on claims to find out which ones are being paid or denied. Enhanced Claim Status submits automatic status requests based on each payer’s adjudication timeline from the date of claim submission, returning the payer’s proprietary responses weeks before the Electronic Remittance Advice or Explanation of Benefits are processed. This gives staff a huge head start on working denials. 7. Difficulty managing denials When errors cause claims to be denied, a response is critical. A denials workflow management solution can optimize follow-up by identifying claim denials, holds, suspensions, zero-pays, and prioritizing denials that need the fastest attention. Denial Workflow Manager also allows organizations to track root causes, which in turn can identify operational changes that can be made upstream, and reduce the denials from happening to being with. Automation is the future of effective claims management Claims management is becoming more complex and demanding, but the digital tools that automate and improve processes can help providers rise to the occasion. It’s now possible to capture and use accurate data, integrate systems and processes to work together, stay up to date on payer requirements, track claim status, and even manage denials efficiently with the help of technology. Learn more about other solutions that can help healthcare organizations with claims management.

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Product featured in this article: Coverage Discovery As of the end of March 2021, more than 53 million Americans have been fully vaccinated, allowing for cautious optimism as we prepare for the next phase of the COVID-19 journey. Unfortunately for pharmacists, the vaccination program has compounded many of the challenges of the last 12 months. Shots may be free to patients, but someone has to pay for them – and getting reimbursed is proving to be a major pain. Complicated billing processes, extra billing audits and mountains of extra paperwork, rejected claims and slow payments are not exclusive to pharmacies helping vaccinate America. With the coronavirus pandemic continuing to muddy the insurance landscape, getting hold of missing dollars is challenging. Healthcare reimbursements haven’t been straightforward for other providers either: widespread coverage loss and uncompensated care is putting extra strain on hospital revenue cycles. With the coronavirus pandemic continuing to muddy the insurance landscape, getting hold of missing dollars is challenging. Providers must find ways to quickly and accurately determine each patient’s coverage status to minimize bad debt. Navigating the complex world of post-COVID healthcare coverage What does the reimbursement landscape look like, one year on? After a long wait, elective procedures are back. But the surge in patient volumes means providers must be on their toes to keep track of coverage. The process for doing so must be streamlined and precise. Ramping up capacity to verify and check coverage without burdensome paperwork is a must. Patient intake is under pressure. More patients are coming through the doors as a result of elective services and vaccination programs (though not always to their usual facility). COVID-19 hasn’t gone away, and with pockets of infection spikes, safety remains a top priority. Capturing adequate insurance information in this context is no mean feat. Running automated coverage checks as soon as the patient arrives will minimize face-to-face contact during admissions and avoid delays. Patient access and collections staff are overburdened. Manual checks are difficult when staff are operating remotely or in a socially distanced environment, and patient information might be incomplete. Automated self-pay scrubbing can help handle the volume. A tool with built-in reporting can also offer insights on workflow and productivity, to help spot opportunities for quicker claims processing. New digital healthcare technologies aren’t always covered by insurers. Telehealth, a life raft during COVID-19, tends to be covered less often by private insurers, compared to Medicare and Medicaid. Coverage checks must factor this in to avoid errors and wasted time. Providers should opt for tools that sweep for payer updates to telehealth coverage to avoid unnecessary delays or denials. Employment levels may be inching upwards again, but tracking coverage remains a challenge as patients start new jobs with new health plans. In addition, checking for Medicare coverage in the midst of changing codes and protocols is time consuming and confusing. A third-party resource such as Coverage Discovery can look for all coverage options and make sure the right bill goes to the right payer. Find missing dollars with Coverage Discovery Hospitals, pharmacists and other healthcare providers can’t afford to continue losing money at a time when every dollar is needed to prepare for “after COVID-19.” Experian Health’s Coverage Discovery is a proven system for tracking down missing coverage quickly and easily, to avoid unnecessary revenue loss. Using billions of data assets and intelligent confidence scoring, it combs through multiple government and commercial payer accounts to maximize actionable coverage. Staff can trust the outputs and focus their attention where it’s really needed. By making coverage identification more efficient and accurate, it’s a shot in the arm for providers in need of faster reimbursements. Contact us to see how Coverage Discovery can be easily integrated into your revenue cycle, so you can maximize reimbursements over the coming weeks and months.

    Many thought the end of COVID-19 was in sight with the availability of a vaccine, and while that is somewhat true, an entirely new set of issues has arrived: how to properly administer and manage the vaccine. Now that a COVID-19 vaccine is approved and underway, providers need to execute a medical billing and coding strategy to sustain vaccination efforts. We interviewed J. Scott Milne, senior director of product management at Experian Health, about what’s changed and what providers can do to prepare. How can providers ensure that vaccine administration codes are billed correctly? The ICD-10 and CPT codes for the COVID-19 vaccine haven’t existed until now, which means providers have a new set of codes to learn and unfortunately, those codes seem to change or update almost daily. As more vaccines are introduced, more codes are also introduced, and not just for the vaccine as a whole, but for each specific dose of the vaccine. For example, dose one of the Pfizer vaccine will have a code that differs entirely from dose two of the Moderna vaccine. Keeping up with these changes isn’t only difficult for provider staff, who are likely already stretched thin, but they certainly don’t want to run the risk of submitting a claim with incorrect information. The errors are what result in denials or undercharges. A solution like Claim Scrubber ensures code sets are current on a daily basis – a necessity for times like these – but applies an extensive set of general and payer-specific edits before preparing the claim for processing. That means claims for vaccine administration are error-free before submission to the payer or clearinghouse. Providers can eliminate undercharges, boost first-time pass through rates and do away with costly, time-consuming rework. But proper coding is only the first piece of the billing puzzle. The second piece is to verify the accuracy of payment received from third-party payers. How can providers ensure that third party payers will reimburse at the contracted rates? Providers can certainly get reimbursed for administering the vaccine, but there are a lot of moving parts to keep up with. For example, both Medicaid and Medicare will reimburse providers for administering COVID-19 vaccines, but the percentage of what is covered will differ by carrier and the reimbursement rates can vary both by state and type of arrangement. Reimbursement rates will also vary amongst private payers. Then there is the variation in reimbursement based on vaccine type and dosage -- vaccines that require a single dose may be reimbursed at a rate different than those that require two doses. Even without the vaccine rollout underway it can be a headache for hospitals and health systems to manage multiple payer contracts and reimbursement methodologies. A solution like Contract Manager will pinpoint variance in reimbursement quickly and easily, accurately pricing claims and comparing actual allowed amounts to expected amounts. It is a tool built to adapt to changes within the industry, so providers can capitalize on emerging reimbursement schemes and changes in payer payment policies. It can also help identify sources and patterns of errors so recurring issues can be promptly resolved. The end result: the provider organization can the payer revenue that is due for vaccine administration. Interested in learning more about how providers can optimize vaccine-related reimbursements?   Other blog posts in this series: Segmenting your patient population for the COVID-19 vaccine Engaging patient segments with convenient, secure scheduling solutions Authenticating portal access with automation Optimizing reimbursements by capturing missing coverage