Claims & Contract Management

It’s only natural to want to be fairly, fully and quickly reimbursed for services – it’s the basic foundation of business. Yet only in healthcare does attaining this basic transactional norm become challenging. Healthcare providers must be vigilant at all stages in the revenue cycle to ensure the amount they receive is timely and accurate. Achieving this deceptively simple goal is dependent upon insight – the ability to discern the true nature of a situation and to respond appropriately. Applying insight at critical points in the claims lifecycle can make a marked difference in reducing denials and accelerating payment.  The foundation of a successful claims management strategy begins with contract management, where advanced analytics and data-driven insight can help you quickly and easily pinpoint payment variances and validate reimbursement accuracy for each of your third-party payers. Ensuring compliance with contract terms allows you to identify recurring issues so they can be promptly addressed, while providing the ability to strategically evaluate overall contract performance. Once you achieve visibility of the contract process, you can apply those findings to other areas, such as claim scrubbing. Boosting the first-time pass through rate eliminates costly, time-consuming rework and speeds reimbursement. A strong claims scrubbing approach involves taking time, prior to submission to the appropriate payer or clearinghouse, to ensure the claim is complete, accurate and meets individual payer requirements. Once the claim is submitted, it’s not a matter of “out of sight, out of mind.” Tracking claim status early in the adjudication process – rather than waiting for a denial to appear on your desk – helps improve cash flow and maintain a healthy revenue cycle. An online payer portal provides instant insight into the status of each claim and gives you the ability to determine if a claim is lost, denied, pending or being returned. Regardless of how well you scrub claims before submission, it’s likely that a certain percentage will be denied. You can optimize and accelerate payments by quickly and efficiently identifying denied claims for analysis and re-submission. Use technology to ensure denied claims aren’t overlooked and streamline the workflow associated with claims management. Finally, taking a comprehensive look at all pending claims and denials allows you to prioritize claims and denials so that your staff can work the highest impact accounts first to improve efficiency and increase revenues.  Advanced technology that provides insight into contracts, payer requirements, claims status and denials holds the key to reducing the claims processing errors that add an estimated $1.5 billion in unnecessary administrative costs to the nation’s health system. Few healthcare organizations can afford to receive less than their fair reimbursement for the care they provide. By implementing a strategic approach that grants insight into each component of the process, healthcare organizations can bolster the bottom line and streamline efficiencies along the way. To learn more about how to turn these strategies into tangible results, register for our Dec. 3 Webinar, “5 Ways to Accelerate Your Claims Payments."

Remember those commercials for the hamburger chain in the mid-1980’s? An elderly lady angrily shouted, “Where’s the beef?” in response to seeing a tiny burger on a large, fluffy bun. If that same creative concept were applied to healthcare today, perhaps the lady would proclaim, “Where’s the data?” when looking at the revenue cycle. While healthcare as a whole is moving toward using clinical data and analytics to enhance patient care, most organizations aren’t realizing the true potential of financial data to drive revenue cycle performance. So where does that potential lie? Quite simply, it lies in the vast amounts of financial data that healthcare organizations can access, yet do so ineffectively. By leveraging this existing data more appropriately, organizations can build and sustain margins while improving performance and enhancing the patient experience. Consider these three areas of opportunity to use data to drive the revenue cycle. Patient Access Correctly capturing and analyzing patient data at the initial point of contact allows an organization to reap large rewards, both clinically and financially. For example, correct patient identification reduces the risks of fraud and identity theft and ensures that medical records are being provided for the right patient, thus preserving patient safety. In addition, using data to provide accurate estimates of the patient’s payment responsibility up front and developing customized payment plans can elevate patient satisfaction as well as propensity to pay, allowing the healthcare organization to enhance collections and reduce bad debt. Claims and Contract Management Another area of opportunity is in payer contracts and claims. During contract negotiations, data and analytics help identify new service line opportunities for enhanced financial performance. Claims are more accurate and efficient when analytical tools review them before submission, comparing them with contract requirements and kicking out those with errors or ones that require further information. Consider the example of a healthcare organization that improved its recovery rate on denials by almost 50 percent by leveraging data to compare the amount received for the claim with the contracted amount. Collections Data and analytics also can be used to improve internal collections efficiency and profitability. Organizations can use data to segment accounts that share demographic and financial profiles, rather than simply looking at balance amounts and number of days open. This allows collections staff to prioritize work based on a patient’s likelihood to pay, which improves both collections and the patient experience. For example, a patient scoring in the “most likely to pay” segment may not need a call until day 75, while someone in a lower segment may need additional calls and help setting up a payment plan within the first month. Segmenting in this way not only increases the likelihood of successful payment, it preserves patient satisfaction at the same time. Realize your revenue cycle’s true potential by leveraging financial information to enhance performance. Moreover, marry these activities with efforts to use clinical data to improve care, and you can realize a comprehensive approach to elevating overall quality and performance. You’ll no longer need to ask, “where’s the data?” Learn more about leveraging data and analytics to drive the revenue cycle with this white paper: The new revenue cycle imperative: A data-driven approach to minimizing risk and optimizing performance.