Tag: Claim Scrubber
An efficient revenue cycle management (RCM) system is a win-win for patients and providers. Friction-free solutions that cover everything from booking appointments to paying bills create a more satisfying patient experience and allow patients to focus on their health. Providers can lower administrative costs and generate more revenue from data-driven billing and collections operations. To ensure the patient’s financial journey goes ahead without a hitch and avoid revenue leakage, the RCM system can’t skip a single step. Experian Health’s 10-step healthcare revenue cycle flowchart sets out the necessary ingredients for success. See the healthcare revenue cycle flowchart below: Step 1: Patient registration The healthcare revenue cycle flowchart begins with the patient’s first interaction with the healthcare organization. First impressions count. Patients want to be able to book appointments and complete registration quickly and easily, and providers that offer patient portals are seen as more attractive. Opening up the digital front door with online self-scheduling and self-service registration also helps providers increase operational efficiency and minimize manual errors that could lead to claim denials. Reliable patient intake software can verify patient identities, reduce manual processes and deliver a flexible patient experience – laying the groundwork for the entire RCM process. Step 2: Eligibility and benefits Next, providers need to check whether the patient’s insurance plan covers their expenses. To increase the likelihood of reimbursement, providers should give patients clarity about their coverage status and be vigilant about locating any missing or forgotten coverage. Coverage Discovery allows providers to check for undisclosed coverage at every patient touchpoint. By quickly uncovering previously unidentified coverage, bills will be cleared sooner with fewer write-offs to bad debt. This part of the RCM process is also a good time to help patients plan for their financial obligations. Patient Payment Estimates gives patients accurate estimates and links to financial assistance and easy payment methods, straight to their mobile device. With the right data and digital tools, providers can deliver a transparent, compassionate and convenient patient payment experience that encourages payment earlier in the revenue cycle and supports a healthy cash flow. Step 3: Data entry With RCM processes relying on data like never before, maintaining accuracy is paramount. Providers must be able to verify and protect patient identities to ensure the right information is linked with the right patient. Accurate data entry decreases the costs associated with medical billing errors, and improves interoperability as more patient data is created, collected and shared. A digital patient identification solution can build a single, accurate view of each patient, using a unique patient identifier to hold the information together like a golden thread. Automated patient enrollment using PreciseID® allows existing data to be auto-filled, while tools such as Universal Identity Manager maintains data in an interoperable format, to further protect against errors. Step 4: Prior authorizations Before treatment begins, providers must determine if prior authorizations are needed. If so, they must submit a request to the payer. Without prior authorizations, providers may see their claims denied, which increases costs, causes time-consuming rework, and creates a stressful experience for patients. With online prior authorizations, providers are guided through a workflow that automates inquiries, status checks and submissions. It auto-fills payer data using real-time information about each payer’s prior authorization requirements, stored in Experian Health’s pre-authorization knowledgebase. Prompts for manual involvement ensure the process is as efficient as possible, to expedite treatment and secure timely payments. Step 5: Patient encounter At the time of treatment, information about the services a patient receives will be added to their patient record. This sets the stage for accurate coding and billing. To ensure no essential information is omitted, providers must keep up to date with regulatory changes. For example, the Appropriate Use Criteria program introduces new requirements for providers ordering diagnostic imaging services. Providers should examine their workflows in advance to avoid any costly compliance errors. The patient encounter is also an opportunity to double down on creating positive patient experiences, and to anticipate any potential RCM issues. Communicating clearly about any changes to medical bills and checking again for coverage will keep the revenue cycle moving. Providers may also consider incorporating data on the social determinants of health to support efficient discharge planning and prevent high-cost readmissions. Step 6: Charge posting In the next step of the healthcare revenue cycle flowchart, providers must submit the claims to the relevant payer using the appropriate charge posting or charge entry process. Documentation must include a detailed breakdown of all the services provided to the patient, alongside patient information, history and insurance or payment plan status. Again, getting every detail right will secure more timely payments that match the expected amounts. Step 7: Coding and billing Before patient billing gets underway, providers must check payer codes for the services that have been delivered. Payers use diagnostic (Dx) codes, place of service (POS) codes, current procedural terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and others to determine payable amounts. If codes are not inputted correctly, claims are likely to be denied. Automated claims management software can check that every claim is clean and error-free before being submitted. Experian Health’s claims management software incorporates standard government and commercial payer’s global edits as well as client-specific customized edits so providers can submit claims with confidence. J. Scott Milne, Senior Director of Product Management at Experian Health, says providers can leverage tools such as Claim Scrubber and ClaimSource to automate and prioritize claims to maximize reimbursement: “Both of these solutions are focused on the most important revenue cycle goal – to submit the claim correctly the first time. With the combination of Claim Scrubber and ClaimSource, healthcare organizations give themselves the opportunity to decrease denial rates, increase cash flow and decrease the overall accounts receivables.” Step 8: Claims management After the claim has been filed, the payer’s claims adjudication process begins. Payers will check eligibility, benefits, coding and contract rules to determine their financial responsibility. They may decide to pay in full, pay a partial amount, or deny the claim, with the reasoning set out in an Explanation of Benefits (EOB) statement. If the claim is denied, the provider needs to decide if it’s worth reworking and resubmitting the claim. Rework is expensive and time-consuming, so many providers use a healthcare clearinghouse to check claims before they’re submitted. Providers may also consider using a tool like Enhanced Claim Status, which submits automated status requests based on payers’ individual timelines, and provides responses that include the payer’s proprietary codes and descriptions. This facilitates early intervention into claims that are flagged for denial, which improves productivity and faster reimbursements. Providers also get detailed denial analysis and monitoring reports to pinpoint the root cause of denials, so they can be fixed promptly. Step 9: Payer Contract Management The complexity and volume of payer contracts can leave providers with little negotiating power when it comes to querying and collecting underpayments and delays. Providers need robust processes to audit payer performance and keep track of changing payer requirements to ensure timely reimbursements. Experian Health’s Contract Manager helps providers stay on top of changes to payer payment policies, identify patterns of non-reimbursement, and appeal denials in the most effective way. It identifies inconsistencies between pricing claims and paid amounts, so providers avoid missed revenue opportunities. Positive provider-payer relationships make the revenue cycle management process easier for everyone. With reliable contract management tools, communication and two-way accountability are much more effective. Step 10: Patient Billing and Collections The final step in the healthcare revenue cycle management flow chart is to bill patients for the remaining amount they owe. Balances are collected by in-house collections teams or outside collections agencies. Revenue cycle management software makes this process smoother and more efficient. For example, Patient Financial Clearance assigns each patient to the appropriate financial pathway based on their individual circumstances, while Collections Optimization Manager can be used to build custom segmentation models and workflows. That way, resources can be focused on the accounts most likely to yield revenue. Then, once the patient’s bill has been issued, collections software can be used to create a compassionate and convenient payment experience and complete the revenue cycle. Find out more about how Experian Health’s Revenue Cycle Management Solutions help healthcare organizations deliver outstanding patient financial experiences, optimize RCM workflows and increase cash flow.
The payer policy rollercoaster has taken a few twists and turns recently, leaving healthcare organizations out of the loop if they try to keep pace with payer requirements using manual systems alone. Keeping track of changing payer requirements has long been a major challenge for providers, but several shifts in the reimbursement landscape have prompted payers to implement updates at rates providers may struggle to match. More flexible policies permitted during the pandemic are being rolled back, altered employment patterns are influencing insurance plan administration, and new clinical delivery models (such as telehealth) are necessitating different coding structures. Healthcare providers that fail to keep up with these changes could end up wasting many hours and resources to rework claims. Instead, they should consider using automated payer alerts to ease the administrative burden, keep a lid on denial rates and protect profits. Automated payer alerts give providers the power of knowledge For many providers, staying on top of payer requirements involves recurring calendar reminders to check payer websites, subscribing to payer newsletters or social media accounts, or poring over industry media coverage for a hint at possible changes to come. If these checks were automated, providers could save hours of valuable staff time, and feel confident that no vital details are missed. With automated Payer Alerts, providers get instant access to the payer policy and procedure changes they’re too busy to catch. It’s a simple and convenient way to monitor modifications so claims can be submitted correctly the first time. This means staff can spend less time researching changes to procedures. Through an online portal and daily email digest, providers get timely alerts about payer changes posted on more than 120,000 different web pages. Every notification is the result of extensive behind-the-scenes work by Experian Health’s proprietary software. The program generates alerts with a detailed summary of changes, a link to the affected policy and a breakdown of changes by healthcare specialty. This allows providers to prioritize those that are most relevant to their organization. Client success story: Payer Alerts pay big dividends Being in the loop about what’s covered and what’s not puts providers in a better position to protect revenue by enabling more efficient allocation of resources, minimizing claim denials and avoiding missed revenue opportunities. New York-based University Physicians Network (UPN) implemented Payer Alerts to help physicians avoid denied claims. The CEO said, “Payers are increasing their edits, but if you know about them ahead of time and can make the required adjustments, you can avoid both denials and time-consuming appeals. With Experian Health, we now have an automated, straightforward process that helps us minimize unnecessary denials and take a proactive approach.” One UPN group recovered $42,000 as a result of a Payer Alert on a single policy change. Amplify results with the right healthcare payer solutions Payer Alerts helps healthcare organizations streamline their workflow and maximize revenue through more than just its immediate features. Its compatibility with other automated healthcare payer solutions can build the perfect defense against payer reimbursement challenges. For example, combining Payer Alerts with Contract Manager and Contract Analysis helps hospitals manage multiple payer contracts and checks that the correct amount has been reimbursed. Contract Manager allows providers to monitor payer performance and arms them with the data to negotiate more favorable contracts. It generates reports that support better communication with payers. This results in fewer phone calls to resolve issues and reduces the likelihood of misunderstandings over patient insurance status or whether a claim was received. Similarly, Claim Scrubber works alongside Payer Alerts to review every claim and verify that it’s coded correctly before being sent to the payer, to reduce the risk of denials. Claim Scrubber also now includes billing modifiers designed to support compliance with the Appropriate Use Criteria program. Using Payer Alerts to keep pace with regulatory changes Looking ahead, providers must continue to pay attention to legislative changes that affect payer strategies. Implementation of the No Surprises Act and related legislation should lead to greater transparency and more effective data sharing within the healthcare community. However, it also puts pressure on payer-provider relationships. Payer rules may continue to change, which means that payers may interpret these rules differently. Experian Health’s regulatory solutions can help providers stay on top of these changes and avoid penalties. Ultimately, providers can’t respond to changing payer policies if they don’t know those changes have been made. While change is inevitable, losing valuable time and revenue to inefficient manual processes is not. By investing in automated healthcare payer solutions, providers can adapt to change and stay ahead of the game. Find out more about how Experian Health’s Payer Alerts can help healthcare organizations capture the necessary information to make timely and strategic decisions to protect profits.
Claims denials are a major source of headaches for healthcare organizations. On average, denied claims can take more than two weeks longer to pay out than first-time claims, if they get paid at all. Denials can have major downstream impacts, including lower annual net revenue, additional hours spent on administrative work, and potential disruptions to patient care. Claims denials aren’t just an occasional inconvenience, either. A recent American Hospital Association (AHA) survey found that 89% of all hospitals and health systems have seen a rise in denials over the past three years, with half of the participants describing the increase as “significant.” Data from Healthcare.gov confirms this trend. The Kaiser Family Foundation (KFF) states that in 2019, health plans available on the individual market denied an average of 17% of all claims – up from 14% the year before. It’s becoming more critical than ever for healthcare organizations to employ integrated, intuitive, and technology-driven strategies to get their claims paid in a timely and efficient manner. Reduce claim denials by eliminating administrative errors and manual processes Health plans can deny claims for any number of reasons. The good news is that in 2019, KFF found that less than 1% of claims were denied based on medical necessity. The bad news is that the remaining 99% were denied largely due to other reasons. This included referrals, prior authorizations, coverage disputes, data errors, and clearinghouse problems. Many claims denial issues occur when organizations rely on manual processing of complex documents that are subject to ever-changing requirements from a wide variety of payers. Mistakes are not uncommon, and that ends up costing time and money. Smart, intuitive claims management workflows that take advantage of automation technology can augment staff resources and reduce the likelihood of errors. Automation contributes to clean and accurate claims the first time around. According to the Council for Affordable Quality Healthcare (CAQH), manual processing can take an average of four minutes per claim. Automation cuts this time by 25%, bringing the total time per claim down to just three minutes. This might not seem like a lot in isolation; however, it becomes more material when the time savings is applied to a large, multi-hospital health system that partnered with Experian Health to revamp its claims processes. The health system gets through 200,000 claims per month. That could translate into 200,000 minutes saved – or more than 3,300 hours – every 30 days. Amidst the staffing shortages that are persistent in healthcare, those numbers are significant. For providers of all sizes, the right automation tools use an expansive library of national payer edits, supplemented by custom edits, to ensure that claims are clean before they get out the door. These tools can also organize and prioritize accounts to help staff members use their time most efficiently. If a claim does have an issue, organizations can use additional technologies to stay one step ahead of the denials process. Enhanced claim status monitoring can give providers insight into potential problems long before the ERA and Explanation of Benefits are processed. This allows organizations to address known issues and predict their revenue cycle outcomes earlier and more accurately. Automation can also help providers slash even more time off the claims management process. The Council for Affordable Quality Healthcare (CAQH) estimates that it takes between 14 and 30 minutes to complete a manual claims status inquiry. Automated status monitoring can potentially shave 9 minutes off this task, freeing up staff to complete other tasks. There’s still plenty of options when claims do get denied. Providers can complement their claims capabilities with denials workflow management tools that can generate customized worklists, highlight ANSI reason codes and payer proprietary codes, and identify payer-specific denial trends to help inform decision-making. Automation creates a faster, more accurate claims processing ecosystem Most healthcare organizations use a number of different technologies to manage their revenue cycles, and all these systems must work together in harmony. Unfortunately, interoperability across disparate clinical and financial systems isn’t easy to achieve. In the case of the provider that chose Experian Health to improve its claims process, integration with Epic, its medical records system of choice, was very important. For example, ClaimSource easily loaded customized edits and the edits library into Epic, tracked and corrected claims, and found and repaired issues with the system build, creating opportunities for cross-training and centralized reporting. Thanks to this automated, integrated process, this provider improved its acceptance rate by 10 percent, consistently seeing 99 percent of its claims accepted. Additionally, its clean, paid claims percentage increased by over 10 percent, creating a more predictable, profitable revenue cycle. With denials on the rise in an increasingly challenging claims management environment, providers will benefit from replacing manual processes wherever possible. Automation is the key to optimizing staff resources and significantly reducing reimbursement obstacles. To see sustained success with your revenue cycle, get in touch with Experian Health and start automating your claims process today.