First Pst after migration to Cloud in Health care Blog

In 2009, processing claims was listed as the second greatest contributor to “wasted” healthcare dollars in the US, at an estimated $210 billion. A decade later, that amount was estimated at $265 billion. Today, healthcare providers are still grappling with denied healthcare claims, with both challenges and solutions accelerated by the pandemic. To put the scale of operational and delivery changes into perspective, Experian Health recorded well over 100,000 payer policy changes for coding and reimbursement between March 2020 and March 2022. The implications for claims processing are immense, which is why healthcare providers need to reevaluate their denial management strategies and invest in new technology that can help increase reimbursements. In June 2022, Experian Health surveyed 200 revenue cycle decision-makers to understand how they feel about the current situation. What are the priorities of those on the front line of denials management? And how can technology contribute to improvements? This article breaks down the key findings. Takeaway 1: Denials are increasing and reducing them is priority #1 30% of respondents say denials are increasing by 10-15% Nearly 3 out of 4 respondents say that reducing denials is their top priority For most respondents, claims management is more important now than it was before the pandemic, because of payer policy changes, reimbursement delays and increasing denials. Respondents attribute this to insufficient data analytics, lack of automation in the claims/denials process and lack of thorough staff training. When it comes to improving denial rates, staffing seems to be the greatest challenge. More than half of respondents say staff shortages are slowing down claims submissions and hampering efficiency. Shrinking offices mean there is less staff to handle the growing volume and complexity of claims. It’s no surprise, then, that around 4 in 10 respondents are also concerned about keeping up with rapidly changing payer policies and keeping track of pre-authorization requirements. Providers recognize that technology can help reduce denials while easing the burden on staff. A tool like ClaimSource manages the entire claims cycle using customizable work queues that make it easy to prioritize accounts, saving staff time and avoiding the errors that lead to denials. This also incorporates payer edits to ensure that claims are clean before being submitted to the payer. And if claims do end up needing further attention, Denials Workflow Manager eliminates time-consuming manual processes and allows providers to attend to high-risk claims quickly, so there’s less chance of delayed reimbursement. Takeaway 2: Automating denials management in healthcare is critical 52% of respondents upgraded or replaced previous claims process technology in the last 12 months 51% are using robotic processes, including automation, but only 11% are using artificial intelligence Prior to the pandemic, automation was sometimes perceived as a threat to jobs. But with changing employment patterns and evidence of the broader benefits of automation, attitudes are shifting. Automation can make life easier for staff by removing manual tasks to allow them to focus on other priorities. It speeds up the healthcare claims processing workflow, reduces the risk of errors, and enables better communication between providers, patients and payers. Providers recognize that automation drives more efficient claims management. The survey revealed that 45% of respondents turned to automation to keep track of payer policy changes, 44% had automated patient portal claims reviews, and 39% had digitized patient registration in the last year. Automation supports all stages of the claims management process, from auto-filling patient data during registration, to generating real-time claim status reports for back-office staff. Payer authorizations were a common challenge for providers, and a perfect fit for automation. Experian Health’s Prior Authorizations solution eliminates the need for staff to visit multiple payer websites, automates inquiries, and offers real-time updates on pending and denied submissions so staff knows when to intervene. Takeaway 3: Providers are searching for denial management solutions that will achieve the greatest ROI 91% of those likely to invest in claims technology say they will replace existing solutions if presented with a compelling ROI The majority of providers may be on the lookout for better claims management solutions, but they vary in how they measure ROI. Predictably, one of the most common metrics is how much staff time can be saved, with 61% concerned with hours spent appealing or resubmitting claims, and 52% looking at time spent reworking claims versus reimbursement totals. Rates of clean claims and denials were also popular metrics, at 47% and 41%, respectively. Using Denials Workflow Manager and ClaimSource alongside additional claims management solutions like Claim Scrubber and Enhanced Claim Status can deliver an even stronger performance against the above metrics. Each solves a specific challenge within the claims management workflow, but when used together, the ROI is multiplied. Overall, there’s optimism that digital technology and automation can help healthcare providers improve claims and denial management and reduce the amount of “wasted” dollars. This survey shows that providers are keen to grasp the opportunities offered by automation to optimize the reimbursement process and get paid sooner. Download the report to get the full results on the State of Claims 2022, and discover how Experian Health can help organizations with their denial management strategies.

Full implementation of the Appropriate Use Criteria program has been indefinitely delayed, giving providers more time to prepare. The Centers for Medicare and Medicaid (CMS) introduced the consultation mandate to ensure that advanced diagnostic imaging services would be provided to Medicare beneficiaries only where medically necessary. Originally slated to commence in January 2022, the penalty phase had already been pushed back until January 1, 2023, at the earliest, due to logistical challenges and concerns about the administrative burden on providers. While penalties for non-compliance won’t kick in just yet, claims submitted before full implementation could still be subject to denial. Providers should take advantage of the extended educational and operations testing period to stress-test their pre-claims infrastructure for any Medicare claims that would fall under the program or that require other forms of pre-authorization. This means implementing alerts to comply with the Appropriate Use Criteria program and prior authorizations requirements To support providers to manage these changes, Experian Health’s Prior Authorizations solution now includes informational alerts for Medicare plans where a patient order needs to comply with AUC or requires prior authorization. Recap: what the Appropriate Use Criteria program means for providers The AUC program requires providers to consult a Clinical Decision Support Mechanism (CDSM) any time they want to order specific advanced diagnostic imaging services for certain Medicare outpatients. The CDSM online portal will check the patient’s record to confirm whether AUC requirements apply. The ordering physician must pass on this information to the imaging services provider. Any physicians whose ordering patterns are considered outliers will need to seek prior authorization. The process for this hasn’t yet been determined. To secure reimbursement for diagnostic imaging services, imaging service providers will need to have the appropriate certificate of compliance. This means that while the administrative responsibility lies with the ordering provider, the financial consequences of non-compliance sit with the service provider. That may or may not be the same facility. Clear communication, robust records management and interoperable data will be essential to avoid claim denials. Pitfalls of manual prior authorizations and pre-claim reviews Many healthcare providers still rely on manual paperwork for prior authorizations and pre-claim reviews. However, these processes are inefficient and prone to error, especially as claims increase in volume and complexity. The Council for Affordable Quality Healthcare (CAQH) estimates that manual status inquiries take up to 30 minutes each, with automated alternatives reducing this by up to a third. The financial impact is compounded by staff time wasted on unnecessary rework, non-compliance penalties and denied claims. Automated compliance checks can help ensure that no pre-claim requirements are missed. With tools such as Experian Health’s online prior authorizations solution, claims are more likely to be complete and compliant, denials will be less likely, and staff will be able to work more efficiently than if they attempt the process manually. This online service automates prior authorization inquiries with auto-filled payer data, only prompting users when their involvement is needed. Inquiries take place behind the scenes, using dynamically updated knowledgebase stores. Now, the knowledgebase will facilitate quick checks to see if a procedure also requires AUC adherence and alert users accordingly. Enhanced automated pre-claim checks for cleaner claims the first time The new informational alerts are the latest enhancement to Experian Health’s pre-claim management solutions to help providers stay compliant. Earlier in 2022, the Medical Necessity application was adapted to include informational alerts when a procedure needs AUC adherence or prior authorization for Medicare patients. Medical Necessity prevents denials and fines by automatically validating medical necessity checks for Medicare claims. Beyond requirement checks for Appropriate Use Criteria and prior authorizations, automation can also be used to improve other aspects of claims management increase claim accuracy and avoid denials. For example, Claim Scrubber reviews each claim line-by-line, verifying that the claim is coded correctly before it’s submitted to the clearinghouse or payer. Claim Scrubber generates general and payer-specific edits, which now also include AUC adherence checks. Users receive alerts with detailed explanations of why a claim was flagged, so modifications can be made before the claim is submitted. These tools integrate seamlessly with electronic medical record systems so claims and patient orders can be checked against payer rules for medical necessity, frequency, duplication and updated modifiers, and to ensure patient information is current. This also facilitates a more reliable exchange of information between all those involved in the provision and reimbursement of healthcare services. Not only does this promote compliance with Medicare rules and reduce the risk of penalties and denials, but it also promotes better communication between healthcare organizations to deliver high-quality care and a better patient experience. Find out more about how Experian Health’s enhanced pre-authorization solutions support better claims management and help healthcare providers comply with Appropriate Use Criteria and other prior authorizations requirements.

Healthcare consumers should find it easier to access information about how much their care will cost, with the Government’s twin price transparency final rules both now in effect. The Transparency in Coverage Final Rule came into effect on July 1, 2022, placing new requirements on health insurers to disclose rates for specific items and services. This follows the similar Hospital Price Transparency Final Rule, which came into effect in January 2022. Taken together, the regulations are a significant step toward helping Americans understand and plan for the cost of care. However, this means that providers will need to implement healthcare price transparency tools to help them follow these regulations. While it remains to be seen how health insurers will fare, implementation has not been straightforward for many hospitals: only 16% achieved full compliance as of August 10, 2022. No fines have been issued yet, but with the maximum penalty increasing from $300 per day to $5500 per day in 2022 (up to $2 million per year), providers are under pressure to resolve compliance issues. To support this, Experian Health and Cleverley + Associates have joined forces to introduce new healthcare price transparency tools that providers can implement now. Bridging the price transparency gap When consumers don’t know how much their care will cost, they’re more likely to delay or default on payments, avoid care, or consider switching to a different provider. Transparent pricing should help consumers shop around for affordable, high-quality services and estimate the cost of care in advance. However, there’s still some work to do to close the gap between expectations and reality. Despite the legislative changes, patients continue to receive inaccurate estimates and unexpected medical bills. Survey data from Experian Health and PYMNTS found that of these patients, 4 in 10 ended up paying more for healthcare than they could afford. Even where the required pricing information is available, it’s often too complex to meaningfully inform patients’ healthcare decisions and financial planning. Experian Health and Cleverley + Associates have partnered together to offer providers a solution for the list of 300 shoppable services and a machine-readable file for items and services offered. This can help providers deliver better patient experiences with accessible pricing information. Healthcare price transparency tools are the key to compliance Under the Hospital Price Transparency Final Rule providers must display payer-specific rates for 300 shoppable services in a consumer-friendly format. Experian Health’s Self-Service Patient Estimates solution facilitates the first requirement, by enabling providers to list shoppable services and deliver accurate estimates to patients. It draws in current chargemaster data, payer-negotiated rates and patient benefits data so estimates are as accurate as possible. Patients receive a personalized estimate with links to convenient payment methods. Providers can deliver a better patient experience and increase upfront collection rates while minimizing the admin burden associated with manually uploading price lists. Similarly, Patient Financial Advisor gives patients a pre-service estimate of their financial responsibility straight to their mobile device, again connected to payment options. It’s designed to arm patients with a clearer understanding of their costs and payment options, so they’re better prepared to manage their financial responsibility. The price transparency mandate also requires providers to make available a machine-readable file for items and services offered by the hospital, including gross charges, cash prices for self-pay patients, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges. Under the new partnership, these machine-readable files are powered by Cleverley + Associates. The files incorporate standardized payer-specific negotiated charge formats and providers can access consultancy support to manage price changes. These files are created using the following process: Model the payer-specific contract terms and rates Apply those terms and rates to patient claims to determine the amount to be paid Assign a Medicare Severity Diagnosis-Related Group (MSDRG) and Ambulatory Payment Classification (APC) to each claim Calculate the median expected payment for items and services by MSDRG, APC and the relevant payer Disclose payer-specific negotiated charge on machine-readable file. An enhanced option is available which allows hospitals to benchmark prices, evaluate different pricing scenarios, and select the most appropriate pricing strategy. That strategy can then be incorporated immediately into the transparency file, so the output is based on the most current data. With this model, Experian Health and Cleverley + Associates can help providers meet both parts of the price transparency mandate. Leverage price transparency investments to improve consumer satisfaction While upfront estimates and clear pricing information are essential for compliance with the Final Rule, providers can further assist patients to manage payments by offering swift support to those who are entitled to financial assistance. Patient Financial Clearance automatically screens patients before or at the point of care to see if they’re eligible for financial assistance, Medicaid or other financial support. Experian’s proprietary Healthcare Payment Risk ScoreSM predicts propensity to pay, so patients can be assigned to the most fitting financial pathway. The final piece of the patient-friendly pricing puzzle is offering clear and convenient ways to pay. Patients welcome a choice of payment methods, including access to the same digital payment tools they use in other purchasing experiences. Experian Health’s Patient Payment Solutions enable providers to securely accept multiple payment types, including eChecking, credit cards (which can be kept on file), and recurring billing. PatientSimple brings all of this together to allow patients to pay balances, see payment plans and apply for charity care via a single self-service portal. Find out more about how Experian Health and Cleverley + Associates are supporting healthcare organizations to implement price transparency tools, comply with regulations and deliver outstanding patient experiences.