Tag: claims management

There is no question that providers’ bottom line has been hit hard this year, and a new surge in COVID-19 is bound to threaten hospital finances once again. As healthcare providers look to supercharge their payment velocity during these uncertain times, it’s worth taking a step back to examine the revenue cycle management process as a whole: what it is, how it works, and the clear actions providers can take to improve the process overall. Below is an overview of healthcare revenue cycle management and how specifically providers can improve their bottom line now and after the pandemic subsides. What is revenue cycle management? Any business, regardless of industry, needs to develop successful processes and strategies for remaining financially healthy. For hospitals and health systems, that process is revenue cycle management. To run a successful healthcare organization, providers must employ and manage accurate and efficient billing processes. Without it, these organizations will likely have to close their doors and will, as a result, no longer be able to provide quality care for their patient population. How revenue cycle management works in healthcare To put it simply, in order to generate revenue for their organization, providers need to collect payments for services rendered. The process of doing this, however, isn’t always as straightforward and simple as it seems. Think of healthcare revenue cycle management like a journey. It starts when a patient schedules an appointment and ends when all patient payments for medical service(s) received have been collected. As we move through the journey, providers have a lot to manage, starting first with front-end intake process, moving all the way through the back-office operations to ensure payment is ultimately secured. Phases of the revenue cycle management life cycle The revenue cycle management life cycle spans several phases: Schedule visit and secure estimate. To kickstart the process, a patient will book an appointment with a provider or specialist and administrative staff will handle insurance eligibility verification and ultimately establish a patient account for that organization. This is also an opportunity for providers to offer price transparency and provide an estimate for services to be rendered. Registration and check-in. An early and vital step for optimizing the entire revenue cycle management process, this is where providers capture details like medical history, insurance coverage and other patient demographics. Ensuring correct patient information on the front end reduces the errors that cause rework in the back office. Ensure care is authorized by the payer. Still on the front end, this is where provider staff checks whether prior authorization is required for a particular procedure or service. Not securing authorization in advance of service can lead to costly denials, rework, operational inefficiencies, and a poor patient experience. Receive treatment and discharge. Once the patient is discharged, the services provided will be translated into billable charges and a medical billing code will be assigned to the claim. It is crucial to the revenue cycle that these claims be accurately coded, as the re-work for incorrect codes and subsequent claim rejections can be costly and a drain for productivity. Medical claims submitted. The claim must then be submitted to the payer. Submitting accurate and timely claims maximizes the revenue collected and prevents delays in reimbursement. Rejected claims directly affect an organization’s revenue cycle, making it all the more important to get the claim right before it makes its way to the payer. Even if a claim is denied, is important it be resubmitted as quick as possible. Patient payments and collections. Once insurance reviews the claim and provides their reimbursement, patients are presented with their out-of-pocket costs for services rendered. On-time payments made in full are preferable for a healthy revenue cycle, but that isn’t always feasible for patients, especially now given the current environment with COVID-19. This is where quality collections practices can really help to optimize patient payments and reduce bad debt. Challenges in revenue cycle management Any process with this number of touch points is bound to come with challenges, but two major challenges seem to stand out: claims and collections. Navigating healthcare claims is complex and costly. Providers and facilities often get stuck in a cycle of inaccurate claim submissions, denials, corrections and rebilling that delays reimbursement and negatively impacts financial performance. A lot of denials can be traced back to errors within the claim submission: improper coding, issues with insurance eligibility, missing or inaccurate patient information, or duplicate claim submission. Errors like this on the front-end are a major cause of the headaches experienced by providers further down the line. After claims are submitted, provider staff will monitor and keep track of claim status. Surprisingly, many still use a manual process not only for this, but for managing any claims that are ultimately denied. Without any kind of automation, this is a drain on productivity, time and resources and it becomes more difficult for providers to respond to denied, pending or returned claims in a timely manner for reimbursement. Another prominent challenge in the revenue cycle is collections, notably collecting from patients before or at the point of service. Providers would prefer to collect from patients prior to them leaving the office, but it’s not always possible, and for a few reasons. Patients are increasingly unable to pay their medical bills, more are presenting as self-pay (maybe now more than ever during the pandemic), and some may not be aware of subsequent coverage or that they qualify for charity assistance, all which directly impact providers’ abilities to collect. A lack of price transparency for services can make it even more difficult for patients to prepare financially. Benefits of revenue cycle management Despite its challenges, when done right, there are many benefits of revenue cycle management in healthcare. Effective revenue cycle management not only improves the patient experience but improves staff satisfaction as well. Automating the process (billing, coding, claims management, etc.) reduces a lot of the associated administrative burden, which allows providers to focus on the delivery of quality care. An optimized revenue cycle will also lower the rate of denials. As errors and redundancies are addressed and prevented on the front end, fewer claims will be denied. Maybe one of the most obvious benefits of a healthy revenue cycle is maximized collections and revenue, and faster collection processes, especially when the process is automized. The entire collections process can be expedited, lowering administrative burden while also improving accuracy. How to improve your revenue cycle management We recommend providers take a holistic approach to improving revenue cycle management, focusing largely on automating the process and within the following four areas: Automate access Patient access is the starting point for the entire revenue cycle process. Ensuring correct patient information on the front end reduces the errors that cause rework in the back office. patient access. With an automated, data-driven workflow, providers can reduce the errors that lead to claim denials while simultaneously improving access to care for patients through capabilities like online scheduling. Access is further improved by reducing the friction around patient billing by leveraging real-time eligibility verification to deliver accurate patient estimates at registration. Increase collections There is a definitely a delicate balance between ensuring that debts are collected and fostering a positive patient financial experience. It is imperative providers find a way to maximize patient collections while also increasing patient satisfaction. Patient access staff must be the patient’s advocate while also improving the organization’s ability to collect from the patient and payer. By leveraging a data-driven approach, staff can verify patient identity and insurance coverage as well as provide an accurate estimate of payment responsibility ahead of service. Staff even can review data to assess ability to pay and evaluate various payment plan and/or financial assistance options. The further upstream the revenue cycle can be managed the more effective the process will be to ensure the patients are informed prior to service, so they can make their portion of their payment responsibilities as early as possible to accelerate the cash collections for providers and to reduce the need to put significant effort into late stage collections. Streamline claims Providers can improve financial performance with automated, clean and data-driven medical claims management. By integrating claims management software with customized edits into the workflow system, providers can thoroughly review every line of every encounter and verify that each claim is coded properly and contains the correct information before the claim is invoiced and submitted for reimbursement. Encounters can be processed in real time with automatic alerts for incorrect codes or other potential issues before the claims submission. Responses include a detailed explanation of why a claim was flagged, so any necessary modifications can be made prior to submission. Increase reimbursement Healthcare organizations that don’t stay current on payer policy and procedure changes risk payment delays and lost revenue. It can also be difficult for providers to verify the accuracy of payment received from third-party payers. With automated access to the right data, providers can be reimbursed more accurately and quickly, while also strengthening their relationships with payers. Providers can avoid payment delays and lost revenue with automated payer policy and procedure change notifications. Solutions that continuously audit payer contract performance can assure that collections align with negotiated terms. The key for successful revenue cycle management Technology, specifically data and automation, is key to the success of the healthcare revenue cycle. Automation ensures problems don’t continue to effect productivity, and data can be matched precisely to predict, model and optimize financial results. Both can also be used to highlight a patient’s financial situation, as well as their propensity to pay, allowing providers to optimize collection strategies from the start and get patients on the right programs.

Claims denials put a big dent into the budgets of healthcare providers – something many organizations can’t afford today given the current pandemic. 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? About 90% of claims denials are preventable when healthcare providers automate revenue cycle functions. In fact, providers could gain an estimated $9.5 billion by automating the claims management processes. Here are 5 ways for providers to proactively reduce claim denials. Healthcare providers should shift from reactive to proactive claim denial management, looking at the whole RCM process. On the front-end, that includes streamlining the patient registration process. By achieving near-perfect levels of accuracy on the front-end, providers can prevent costly claims denials and unnecessary re-work on the back-end of the revenue cycle. On the back-end, ideally, providers will use technology to prevent denials in the first place, improve processes for managing denials when they do occur, and then use a robust analytics platform to understand what went wrong so it can be avoided in future.

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 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.

In its first year of consideration, Experian Health’s ClaimSource® solution garnered the 2017 Category Leader title for claims management. This was achieved by having products and customer support that address the top issues in Patient Accounting, including: Declining reimbursement making it more important to ensure accurate payments Slow payment from third-party payers Having to make analytics-based key financial and operational decisions Constantly changing governmental mandates and payer requirements Managing the move from fee-for-service reimbursement to value-based reimbursement The challenge of finding skilled resources The continual stress to do more with less The Experian Health ClaimSource product suite addresses these challenges first by providing excellent products that are all seamlessly interfaced and can provide exception-based processing for: Automation of processing clean claims through the use of an expansive library of national payer edits The ability and willingness to create provider specific custom edits Expediting the follow up process thru the use of enhanced claims status detailed responses Enabling more efficient processing of denials by analyzing denials reasons and automating workflow Automating the payment posting process with customized posting files for handling splits and contractual adjustments Providing the best interfaces available for Epic clients for both hospital and physician billing offices We follow that up by offering superior customer support for our clients. By leveraging our size, experience, and multiple locations in Sacramento, California and our new location in Schaumburg, Illinois, we support clients from Hawaii to New York to Alaska to Florida and everywhere in-between. These two offices allow our clients to get great hands on support for implementations, training, extensive custom programming, as well as experienced billing analysts with decades of billing knowledge. We always thought our claims products stood out against our competition, but now KLAS has validated that for us. Ask your Experian Health account representative or email us at experianhealth@experian.com to find out how we can help your business office address your specific needs.