Tag: automation

As every healthcare executive knows, a healthy revenue cycle relies on precise paperwork. That’s why all Medicare providers should be paying close attention to the revised medical necessity form, which will be mandatory starting January 1, 2021. Failure to use the new Advance Beneficiary Notice of Non-coverage (ABN) form could lead to denied claims, financial penalties and a subpar patient experience. We interviewed Theresa Marshall, senior director of data compliance at Experian Health, about what’s changed and what providers can do to prepare. What is a medical necessity form? Medicare only pays for services and procedures considered “medically necessary.” In situations where a procedure isn’t considered medically necessary, providers must issue the patient with an ABN which ultimately transfers financial responsibility to the patient. Services that could be considered medically unnecessary might include treatment in hospital that could have been provided in a lower-cost setting, screening or therapies that are unrelated to the patient’s symptoms, or hospital stays that exceed a specified length of time. Perhaps a patient is receiving support with personal care from a home health agency – this may not be strictly medically necessary, so the provider might anticipate that it won’t be covered by Medicare. An ABN isn’t required for services that are never covered by Medicare, such as dental care or cosmetic surgery. What’s changed on the new medical necessity form? The new form, CMS-R-131, replaces the version released by CMS in June 2017. The main change is the addition of new instructions for Dual Eligible beneficiaries. These are patients who are eligible for both Medicare and Medicaid, and most likely enrolled in the Qualified Medicare Beneficiary Program (QMB), which means Medicaid pays for any Medicare-covered services. Providers must not levy any charges against QMB patients, or they’ll face sanctions. The new instructions specify that in addition to edits that strike through specific language, “dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN for a claim to be submitted for Medicare adjudication.” How should providers prepare? Should they chose, providers can start using the new form now. The important thing to remember is that they must have the new form in place by the new year. Any outdated forms after the first of the year will be invalid. Many providers are still using manual processes which require checking medical necessity rules for both Medicare and commercial payers via the CMS website, then calculating and preparing the required paperwork themselves. This can be time-consuming and vulnerable to errors, which also results in denied claims and extra days in accounts receivable (A/R) – not to mention the extra stress it causes for patients. A time-saving alternative is an automated tool such as Experian Health’s Medical Necessity. With automation, you can validate clinical orders against payer rules quickly and accurately, for cleaner claims the first time around. Medical Necessity integrates seamlessly with multiple electronic medical records (EMR), scheduling and registration systems, to run automatic checks for medical necessity, frequency and duplication. With up to half of denied claims occurring early in the revenue cycle, any actions to minimize errors and delays during registration could bring big financial benefits. Medical Necessity from Experian Health will include an automatic check of a Medicare beneficiary’s QMB status ahead of the January 2021 deadline, so the electronic ABN can be updated immediately, ready for the patient’s signature. Could this improve the patient experience? Yes, definitely. In addition to reducing manual processes, preventing denied claims and protecting against lost revenue and financial sanctions, automating medical necessity checks also creates a much less stressful experience for patients. For individuals who are financially vulnerable, any lack of clarity about their medical bills can be a huge source of worry. But when providers can quickly identify patients who shouldn’t be charged, the billing experience is a much smoother ride. Medical Necessity is just one of the many ways that Experian is working to reduce the burden on hospital resources, improve patient experiences, and ensure that hospitals are fully compensated for the care they provide. Find out how we can help your organization get your paperwork in order in time for the new ABN requirements in January 2021, so you can offer a better patient experience and reduce claim denials at the same time.

In previous winters, anyone struck by a sore throat or fever might assume they had flu, and head to bed with a hot drink and some painkillers. This year, the looming specter of COVID-19 could prompt those with flu-like symptoms to seek medical care instead. Combined with a likely second wave of COVID-19 cases as lockdown requirements relax, healthcare organizations anticipate a surge in patients seeking tests and treatment this winter. To protect against a possible “twindemic”, where COVID-19 and winter flu season collide, providers will want to ensure the patient intake and access process is as easy and efficient as possible—and not just for regular appointments with a primary care physician or specialist, but for pandemic- and flu-related services like COVID tests, flu shots, and more. Online scheduling has been a game-changer during the pandemic: could it be the key to surviving a twindemic? With the right digital tools in place, providers can screen patients for their COVID-19 or flu risk before attending an in-person appointment, helping separate healthy patients from those suspected of having either illness. Providers can also leverage those same digital tools to streamline activity like flu shots, or even drive-through testing for COVID-19. Four ways to leverage digital scheduling for a twindemic These four steps could be key to protecting patients, streamlining workflows and reducing pressures on call centers during flu season as it collides with COVID-19: 1. Create screening questionnaires during patient scheduling As soon as the patient logs on to book an appointment, they are asked to answer a few short questions about their symptoms. A screening questionnaire can triage people wanting to get tested, while the answers inform providers of the likelihood of a patient having COVID-19 and if that individual needs to quarantine. After being screened, the system can direct patients through the correct channel of care based on the information provided. A similar questionnaire could be adapted during flu season for providers to assess and compare symptoms and risks ahead of time. Providers can even designate day and time slots available to patients for flu vaccinations, making it easy for patients to schedule on their own time and further minimizing the risk of unnecessary contact with other patients in office. 2. Direct patients to drive-through testing to minimize in-person tests Depending on the answers given during screening, patients may be directed to virtual and disease-specific care, such as drive-through COVID-testing. An online scheduling platform can easily be used to book appointments for tests, presenting patients with any available time slots, either same-day or a few days out. The platform can also record information about the patient’s vehicle to quickly identify patients and avoid bottlenecks in the drive-through. With so many patients hesitant to show for in-person visits today, a similar system for flu shots could serve providers well. 3. Use guided search to direct patients to the right virtual services Virtual care has proven both necessary and valuable during the current pandemic. Not only has it kept patients in close contact with providers and specialists, but it has helped providers capture revenue lost from the cancellation or delay of in-person appointments. Virtual care will be increasingly critical during a dual COVID-19/flu season. By asking the right questions during online scheduling, patients can be connected to the correct provider, whether virtual or in-person, for their needs and book an appointment quickly and easily. 4. Eliminate walk-through traffic at urgent care centers Urgent care centers are already known to be the ‘doctor of choice’ for many patients, but this could pose a few challenges for both patients and providers during a dual pandemic. Rather than be a gathering spot for patients with both illnesses, urgent care centers may want to consider switching to an appointment-only system, where appointments must be scheduled online or by phone. This can help reduce the number of in-person visits and walk-in traffic, which will not only help keep everyone safe and healthy but contribute to a far better patient experience as patients wouldn’t have to sit and wait to be seen by a provider. Interested in hearing more about how online scheduling could help your organization manage flu season as it collies with COVID-19?

Patients today expect digital capabilities from their provider and will increasingly choose those who offer digital capabilities. Knowing this, many providers have been working to shift more of the patient journey online, through telehealth and virtual care. Not all care needs to be delivered face to face, and technological advances allow patients to access more services from the comfort of their own homes, at a time that suits them. This trend has been visible for a few years now, as consumers sought out more smartphone-friendly digital healthcare experiences. But change in the healthcare industry often comes at a lumbering pace, so when the coronavirus pandemic hit and accelerated the transition to remote care, many organizations found themselves on the back foot. Now, it’s a case of catch-up, keep up or get left behind. As demand for telehealth services grows, so too does the regulatory framework around it. A big part of staying competitive will be the ability to keep track of new telehealth regulations and changing payer rules. Those that don’t will find their collections straining under the added pressure of missed reimbursement opportunities. How can providers stay on top of the changes and maximize reimbursement? Keeping track of telehealth reimbursement regulations Since early March 2020, the federal government has moved to make telehealth more accessible to patients with Medicare coverage. Limitations on the types of clinicians that can provide telehealth services under Medicare have been waived, while Medicare beneficiaries in rural areas and those with audio-only phones can now access care remotely. New telehealth services will be added to the reimbursable list under a quicker process, which is a huge benefit to both patients and providers, but will mean the rules around reimbursement could change more frequently. Speaking in March, CMS Administrator Seema Verma said: “These changes allow seniors to communicate with their doctors without having to travel to a healthcare facility so that they can limit risk of exposure and spread of this virus. Clinicians on the frontlines will now have greater flexibility to safely treat our beneficiaries.” Flexibility is always welcome – but what do looser rules mean for reimbursement workflows? Three challenges stand out: Payer variation. Telehealth and telemedicine data can be presented differently by different payers, causing a headache for providers during eligibility verification.Coding variation. Each type of telehealth visit is coded and billed differently. Regardless of where appointments are carried out, clinicians must still follow the same billing workflow, so keeping track of the differences is essential.Geographical variation. Providers now have to track billing and coding changes for telehealth services from different payers across multiple states. What can providers do to bill telehealth services as accurately as possible? Billing for telehealth services more frequently calls for a solution that’s flexible enough to keep pace with changing payer rules, and sufficiently scalable to provide real-time reimbursement information when it’s needed. Automation can help achieve both of these goals. Two use cases for automation: Quicker Medicare checks: Run quick and accurate checks to confirm patients are eligible for Medicare coverage for the services in question. A tool such as Coverage Discovery can comb for available coverage, even as patients are switching plans or payer rules are changing. In addition, eligibility verification automations can sweep for coverage information on telehealth services, using reliable and secure third-party data and analytics to check for updates. Cleaner claims submissions: Tighten up billing workflows so that claims can be submitted as soon as possible. Claims management software can run automatic checks so that every claim is submitted clean and error-free. Any missing or incorrect codes can be flagged up, eliminating costly and time-consuming rework. Telehealth alerts can be included as customized edits to confirm whether virtual care is a benefit included in the patient’s current plan. While these actions can help protect your bottom line during the immediate crisis, they’ll also help you build a solid foundation as your telehealth offering inevitably continues to grow. Whether you’re looking to verify coverage, check eligibility or protect patient identities as they log in and use telehealth services, reliable data is key. Schedule a free consultation to discover how Experian Health can help you leverage accurate and real-time data insights to optimize your billing workflow and maximize telehealth reimbursements.

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.

  Artificial Intelligence (AI) and automation are the latest buzzwords in business innovation. But what exactly do they mean, and how can they help your healthcare organization? Put simply (if that’s possible!), AI is when a machine mimics human thinking. It can spot patterns, learn from experience and choose the best solution in a given situation, solving problems with little or no human involvement. While AI is focused on achieving a particular goal, automation is process-oriented. You can set it to follow rules depending on certain data inputs. It’s ideal for completing repetitive tasks efficiently, so the humans in your team can spend their time elsewhere. In healthcare, there are endless opportunities for AI and automation to assist doctors in diagnosing and treating medical conditions, like Microsoft’s “Hanover” machine, which helps oncologists predict the best combination of drugs for each patient. Harvard Business Review investigated 10 promising AI applications in healthcare, which could save the US healthcare system $150 billion per year by 2026. Examples include AI-assisted robotic surgery, faster and more accurate image diagnosis, and determining ideal drug dosages for individual patients. The opportunities aren’t all on the medical frontline either: AI and automation can be of significant value to a hospital’s revenue cycle. But many providers have only scratched the surface when it comes to integrating new technologies within their revenue cycle operations. There are plenty of repetitive processes within the revenue cycle that can be time-consuming, tedious and prone to human error. Thanks to automation, many rote tasks such as handling denied claims and missed authorizations can be taken off your team’s to-do list, keeping productivity high and resource costs low. Here are four ways AI and automation can help reduce claims denials specifically.     Staying on top of ever-changing payer policies Constantly changing payer payment rules create serious challenges for many providers, causing delayed payments, denied claims, increased billing costs and lost revenue. Providers often have no central repository to share updates with the right people across their health system, meaning individual departments have to allocate staff time to digesting the same notifications and newsletters. It’s extremely inefficient and can cost thousands in reworked claims. With automated Payer Alerts you can avoid all of this. Payer Alerts give staff a convenient service that monitors more than 52,000 web pages by more than 725 payers, so you know you’re up to date with any changes. Handy daily email digests notify you of any specialty-specific updates, so you stay a step ahead. John Neumeier from Arkansas Health Group says: “Payer Alerts has been a very valuable tool. Before, our certified professional coders would go out and read all of the payer alerts and manuals from Medicare, Medicaid, Blue Cross and United Healthcare, and try to boil down and assimilate the things that were important to our organization. With Payer Alerts, we’ve got an email sitting there every morning with those things already done for us, so within just a couple of minutes we can scan through and identify what’s important to us, and then very quickly communicate that out to all of our clinics and managers.”     Better patient matching to reduce claims denials A third of all denied claims are linked to inaccurate patient identification. This costs hospitals an average of $1.5 million per year. The go-to solution often involves an enterprise master patient index (EMPI) to match and identify patients electronically. However, EMPIs are limited by their reliance on a single data source – their patient rosters. And if an error sneaks into the patient roster, it’ll be passed down when patient records are matched. Instead, patient matching can be automated using a platform like the Universal Identity Manager. This draws on a variety of broader, more reliable data sources including Experian’s demographic and credit data, then calculates the likelihood that two records refer to the same person. A Universal Patient Identifier is assigned to each patient, so their correctly matched data is always trackable.     More efficient claims verification Your claims team can probably guess the likelihood of a denial based on their experience and data, but actually turning those insights into a robust, efficient process is not easy. Machine learning tools such as Claim Scrubber can look at which claims have been denied in the past and why, and use that data to predict future denials. It tags at-risk claims so you know to run additional checks before sending them off to the payer. Kahlynn Lawrence, Coding Operations Manager from Northwell Health, told us: “It was a way to automate and create a worklist so that the coder could then focus on true coding issues. By doing this we were able to see results… From 2013 to 2017 we’ve been able to reduce our denials by 50% through using the Experian Claims Scrubber tool.” Actionable insights to help optimize your revenue cycle A high-performing revenue cycle relies on powerful data analytics. But monitoring and synthesizing all the data that flows through your organization can be challenging. Machine learning algorithms can help here, giving you deeper insights about the performance of your revenue process. With a business intelligence tool like Analytics, you can leverage multiple datasets to find predictive solutions that boost productivity and maximize your ROI. This tool gathers several data sources into a single dashboard so you can monitor and compare your organization’s performance against your most important KPIs. Industry comparisons and trends analysis will also help you find opportunities for more efficient billing, predictive reimbursement and improved payer performance. Healthcare providers devote vast quantities of time and money to interactions with payers, often due to untracked payer policy changes, error-strewn patient records, or avoidable denied claims. More streamlined revenue cycle management can help you get those claims right the first time. You can stop wincing at the revenue and staff time lost to denials that could be invested elsewhere. So, if you’re looking for ways to do more with less and stop the bleed of rising healthcare costs, perhaps cutting edge AI and automated solutions could hold some of the answers? Visit us at booth #405 during HFMA’s annual meeting or visit www.experianhealth.com/analytics to learn more.