Tag: ClaimSource

Automated claims processing could solve one of the biggest challenges currently facing healthcare providers: maximizing reimbursements by minimizing denied claims. Denials have been steadily increasing over the last few years. An MGMA Stat survey found that nearly seven in ten providers witnessed a jump in denials during 2021, although the trend took hold even before COVID-19 hit. If providers rely on outdated systems and tools to process the growing volume of claims, it's inevitable that denial rates will continue to climb. It's not surprising then that a new Experian Health survey revealed almost 3 in 4 providers stated that reducing claim denials takes precedence over other priorities. Getting claims right the first time is no easy task. Traditionally, the claims management process has been labor and time intensive. Claims teams spend hundreds of hours gathering documentation, preparing claims for submission, engaging with medical clearinghouses, and then monitoring claims adjudication while they await the payer's verdict. Should a claim be denied, more staff hours may be required to rework it for a second attempt at reimbursement. Even if administrative budgets and staffing numbers increased in line with demand, inefficient manual systems can no longer bear the burden of data to be managed. With more providers heading into the danger zone of claim denials, automated claims processing tools are growing in popularity. These enable more efficient claims management, boosting productivity, easing pressure on staff, and above all, minimizing denials. Experian Health's survey found that 78% of providers are open to replacing current technologies if they are presented with compelling ROI projections, reflecting the urgency of the situation. What is automated claims processing? Automating claims involves the use of digital technology, software, machine learning and advanced analytics to optimize healthcare claims management. This can include: pre-filling data into digital forms to avoid data input errors using intelligent document processing to pull unstructured information into a single, usable format comparing data from multiple sources and flagging inconsistencies providing real-time insights and status updates allowing multiple parties to work from interoperable data Tools such as robotic process automation (RPA) can be used to replace manual activities, using data, logic and business rules to make decisions within certain parameters. This eases pressure on busy staff and improves efficiency, for example, when prioritizing claims to be reworked. Imagine how much faster a software program can synthesize hundreds of current and historical data points, compared to a human trying to do the same job. There are opportunities to automate just about every stage of the claim lifecycle, from the patient's first interaction with their provider to reimbursement. For example, automation can be used to: Streamline patient onboarding and automate identity checks to avoid errors in patient information Verify insurance eligibility and run continuous coverage checks to see if the patient's status has changed Maintain a complete electronic health record that follows the patient throughout their healthcare journey, so claims contain correct information Track payer policy changes and apply custom edits so that coding information is correct Scrub claims to find and fix any errors before they are submitted Submit claims to payers and monitor the claims adjudication process Optimize the denials management workflow and prioritize denied claims for resubmission Verify reimbursements and initiate patient billing processes. Virtually any repetitive, process-driven, or paper-based task from claim creation to claim reimbursement is an opportunity for automation. As technology advances, so do the opportunities to streamline operations, reduce time to reimbursement, optimize decision-making, reduce costs and improve the patient experience. Here are the 5 benefits of automated claims processing: 1. Automated claims processing streamlines operations Automation's number one benefit is allowing providers to move away from inefficient and error-prone manual processes. Staff no longer need to sift through disparate and complex coding lists, medical records and payer edits looking for the correct information to attach to a claim. Together with electronic records management, automation allows for standardized workflows, so the entire claims cycle is more consistent, and decisions are based on real-time accurate data. It helps to eliminate time spent searching for missing information, reformatting data to meet payer requirements, and trying to figure out which claims are worth reworking. Multiple digital tools are available to optimize different tasks within the claims processing workflow. But for maximum efficiency, providers should look for solutions that work together within an integrated system. Using a single vendor makes it easier to manage data consistently and simplifies system-to-system interactions. A comprehensive claims management solution also creates a smoother user experience, for example, by allowing staff to check real-time insights within one dashboard, using one log-in. Experian Health's suite of healthcare claims management solutions connects each step in the claims workflow to speed up claims processing. For example, ClaimSource manages the entire claim cycle in a single, scalable online application that serves individual hospitals and physician practices through to large multi-facility health systems. It creates custom work queues and integrates electronic remittance data directly, to allow staff to prioritize high-impact claims and speed up reimbursement. 2. It saves staff time and resources Outdated and clumsy processes can contribute to staff burnout, poor performance and difficulties attracting and retaining top talent, even more so as patient volumes return to pre-pandemic levels. By removing many time-wasting manual tasks, automated claims processing allows staff to use their time more productively. It's particularly important amidst ongoing staffing shortages, which put additional strain on existing staff. Some of the most time-consuming manual activities occur in the prior authorization workflow. Prior authorizations are also a common cause of claim denials. Because payer requirements around prior authorizations change frequently, staff must painstakingly check each payer's website before submitting authorization requests to ensure that the necessary documentation is in place. Once submitted, they must log in to different payer portals to track progress. According to the American Medical Association, some physician practices spend more than two full days processing prior authorizations each week. But with automated prior authorizations, staff can prevent delays and denials. Online prior authorizations automate inquiries and submissions without the need for user intervention, instead drawing on payer data that are already updated and stored in the system. It auto-fills the necessary information and flags where manual intervention is required. It can initiate more authorizations in less time, and guide staff to the highest-priority tasks using dynamic, exception-based work queues. By reducing the error rate, automation also facilitates faster claims processing, which means payments can be processed and issued more quickly. 3. Automation generates more accurate and actionable insights Automation doesn't just save time; it also gives staff greater clarity and control over the claims process. Automated digital solutions facilitate more reliable data management to reduce errors, and generate real-time insights based on accurate information. A large proportion of claims are denied because patient information doesn't match the payer's records. This can be easily avoided using robust electronic medical records that hold data in standardized formats and automatically populate forms with the correct information. Electronic data management also gives staff richer and more reliable insights, by pulling together all the information they need into a single, accessible interface. Using an automated tracker such as Denial Workflow Manager makes it easy for staff to monitor claims, denials and remittances in one place. Not only does it track denials, holds, suspends, zero pays and appeals, but it also provides detailed analysis to help root out the causes of denials, so they can be avoided in the future. Staff can immediately see which claims need attention and resolve them much more quickly, as opposed to using manual processes. Enhanced Claim Status complements Denial Workflow Manager by automatically generating work lists for staff, complete with actionable data to help them check off the tasks quickly and accurately. The software sends automated status requests based on each payer's claims adjudication timeline, to see if claims are pending, denied, returned-to-provider or zero-pay transactions. This takes place before the Electronic Remittance Advice and Explanation of Benefits are processed, so staff can respond quickly and avoid unnecessary denials or delays. 4. Faster claims processing equals faster payment According to the Council for Affordable Quality Healthcare (CAQH), the time saved by switching from manual to electronic claims processing could save the medical industry up to $1.7 billion each year. The increase in accuracy leads to more first-time pass-through rates and optimized decision-making around which claims to rework. While automation requires some upfront investment, the output tips the balance in favor of faster, higher reimbursements. Experian Health's Claim Scrubber solution is one example of how automated claims processing can reduce undercharges and denials, optimize staff time and improve cash flow. This program reviews each pre-billed claim, line-by-line, to check that coding details are accurate. It then applies general and payer-specific edits and verifies that the claim is free of errors before it's submitted to the payer or clearinghouse. As a result, more claims are correct – and therefore paid – the first time, and staff can spend less time chasing old accounts receivable. Case study: Read how Summit Medical Group Oregon – Bend Memorial Clinic reduced A/R days and volume by 15%, and achieved a 92% clean claims rate with Claim Scrubber and Enhanced Claim Status. 5. Automation can transform the patient experience Getting claims right the first time starts at the beginning of the patient journey. A digital patient access experience is more convenient and satisfying for patients and helps prevent errors that can lead to denied claims later. Patient contact information can be automatically pre-filled so the patient can check for errors. If a patient adds new data when they're scheduling or registering for care, that information can be automatically checked against the data already on file, and flagged if there are inconsistencies. Further along, the efficiencies afforded by claim process automation mean patients don't have to wait so long for confirmation that their medical expenses have been handled. Or, if they have an out-of-pocket amount to pay, they'll get clarity about their financial responsibility much sooner. Patient portals are a great tool for helping patients track claims when and where it suits them, rather than having to wait to speak to a call center agent. And by making the claims process more efficient, automation also releases staff from time-consuming repetitive administrative tasks so they're free to support patients with more complex queries. Automation can elevate the customer experience with personalized communications and simplified transactions, from patient access to patient payments. Transitioning to automated claims management As the volume and complexity of claims to be processed increases, providers need to find ways to manage the workload, alleviate pressure on staff and prevent unnecessary revenue leakage. Working with a trusted vendor can ease the transition to automation and maximize potential cost savings. Experian Health provides industry-leading software solutions to improve healthcare claims and denials management so that more claims are clean the first time. In fact, Experian Health was voted as the top claims vendor for hospitals in the 2022 Black Book vendor survey, for the second year in a row. Find out more about how Experian Health's suite of healthcare claims management products can help providers reduce denials, rebilling and drive up reimbursements with automated, clean and data-driven claims processing.

The repercussions of errors on the healthcare claims processing workflow can be major and wide-ranging. It slows the revenue cycle, interrupts cash flow, consumes staff hours, creates frustration for staff and patients, and, in the worst cases, sacrifices revenue. Errors are a perennial—maybe even inevitable—problem but understanding some common reasons behind these mistakes can help. Additionally, digital claims management tools can help you automate claims processing to reduce claims errors, submit cleaner claims, and get paid successfully. In June 2022, Experian Health surveyed 200 revenue cycle decision-makers to understand the current state of claims management. Watch the video to see the results: Any number of claim errors can lead to denials: incorrect medical coding, missing prior authorizations, clearinghouse issues and more. Here are 7 of the most common reasons for claim errors: 1. Claim errors can be caused by missing and inaccurate data “The number one denial issue most providers encounter is eligibility,” says Rob Stucker, Senior Vice President at Experian Health. “These issues begin upstream from the claims process during registration or pre-registration when the patient information that’s collected is either inaccurate or incomplete. It may be as simple as a patient giving their name as Rob instead of Robert, or the registration staff selecting Medicaid as the payer, instead of Medicaid Managed Care. If the eligibility information is even slightly off, the claim will come back as denied.” Collecting accurate demographic and insurance information up-front using digital patient intake tools opens the digital front door and can help eliminate errors during the healthcare claims management process. 2. Manual processes and disparate systems Wherever claims processes are not automated, human error and delays can set in. In addition to typical random glitches and mistakes, many healthcare providers struggle with disparate systems from multiple vendors, in which the front-end and back-end do not communicate seamlessly. Using a single vendor with solutions that manage the entire claims processing cycle can provide holistic help. ClaimSource manages eligibility validation by repurposing Experian eligibility transactions that providers have already run at registration and editing them against the claim.  This process allows providers to double-check the eligibility of the claim before it gets submitted, at no additional cost. In addition, it also does extensive claim editing, submissions, reconciliations, and reporting. This solution creates prioritized workflows and provides access to a national library of documented government and commercial payer edits, as well as custom edits, to meet individual provider needs. 3. Changes in payer requirements can cause claims errors “Providers tell us that a major pain point is constantly changing payer rules,” says Stucker. “Providers are confident that their claims are good, but the payers’ adjudication rules may have changed without prior notice.” The problem here is exponential: voluminous changes multiplied by a range of communication channels (or faulty communication) multiplied again by a proliferation of payers and policies. Keeping pace with these changes is difficult without partner support. “We continuously monitor hundreds of thousands of payer website pages each night for updates,” says Stucker. “When a change is flagged, an analyst looks at it and decides whether it should be added as an edit. We update our huge global library of edits on a weekly or even daily basis. These edits enable ClaimSource and our pre-837 editor, Claim Scrubber to automatically review claims for errors using the most recent payer updates. 4. Prior authorizations Pre-authorizations present challenges at many levels. 8 in 10 providers saw prior authorization requirements increase during 2021. Providers must track changing requirements, obtain authorizations prior to treatment or claims submission, and complete claims that meet complex requirements. When prior authorization requirements aren’t met, appealing a denial can be complicated at best, and many times prove to be irreversible. According to Medical Group Management Association data, a simple denial takes a seasoned biller two to eight minutes to work, but a complicated denial involving prior authorization requirements can take up to an hour to work, largely thanks to time spent on hold. Ensuring claims are completed as required in the first place using a pre-authorization tool, in combination with a claims editor that validates against pre-authorizations, saves valuable time and stress. 5. Short staffing and new trainees Staff hours and expertise are both in short supply, as many providers struggle to retain experienced staff and bring new hires up to speed. Having an automated process with built-in review and analytics can help ensure that claims are completed accurately and quickly. A Council for Affordable Quality Healthcare study found automated claims take 25% less time to process than manual claims, boosting productivity and freeing staff up for the more human-intensive aspects of their work. However, the key is “accurate and user-friendly” automation. A claims vendor should be keeping edits up to date, submitting claims timely and accurately to the correct payer, keep organizations informed on the claim’s status throughout the adjudication process, retrieve electronic remit files, link them to the correct claims, and establish a denial workflow to automatically show denials. This should all be done in an extremely easy to use user interface or directly back into Patient Accounting/Practice Management Systems. If vendors aren’t doing this, then staff will just be working harder instead of smarter. 6. Slow response and follow-through can lead to claim errors  Although delays themselves don’t necessarily cause errors, they can make resolution difficult and time-consuming. Time is always an issue for providers as claims must be submitted in specific time frames from the date of service. Therefore, getting the claim created, processed through a claims vendor and submitted to the correct payer must be done efficiently, or timely filing deadlines are missed.  The same is true for identifying and re-working denials. Denial backlogs quickly become overwhelming, increasing the odds of items slipping through the cracks or re-submission/appeal deadlines being missed. Automating status updates with enhanced claim status monitoring can relieve time-strapped staff of having to contact payers manually for the latest information on claims to find out which ones are being paid or denied. Enhanced Claim Status submits automatic status requests based on each payer’s adjudication timeline from the date of claim submission, returning the payer’s proprietary responses weeks before the Electronic Remittance Advice or Explanation of Benefits are processed. This gives staff a huge head start on working denials. 7. Difficulty managing denials When errors cause claims to be denied, a response is critical. A denials workflow management solution can optimize follow-up by identifying claim denials, holds, suspensions, zero-pays, and prioritizing denials that need the fastest attention. Denial Workflow Manager also allows organizations to track root causes, which in turn can identify operational changes that can be made upstream, and reduce the denials from happening to being with. Automation is the future of effective claims management Claims management is becoming more complex and demanding, but the digital tools that automate and improve processes can help providers rise to the occasion. It’s now possible to capture and use accurate data, integrate systems and processes to work together, stay up to date on payer requirements, track claim status, and even manage denials efficiently with the help of technology. Learn more about other solutions that can help healthcare organizations with claims management.

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.

Navigating an increasingly complex reimbursement landscape remains challenging for today’s healthcare providers, with too many claims still underpaid, delayed or outright denied. In fact, nearly 70% of providers said the problem of denied claims had worsened during 2021. Naturally, relationships with payers suffer, adding friction to the process. To this end, revenue cycle leaders are relying on claims management software to create more visibility into complex contract and claims management processes. These data tools can resolve or prevent the snags that often interfere with claims processing and billing workflows, which allow providers to streamline claims processing, improve communication with payers and accelerate a patient’s payment lifecycle. The path through that bureaucratic jungle requires high-quality information at every step. Accurate patient data, error-free clinical documentation, up-to-the-minute payer policy updates, and verified billing software and claims edits are all essential to help reduce denials and ensure faster-flowing payments.  With so many options on the market, providers should look for healthcare claims management software that provides support in four critical areas. 1. Simplified contract management Managing and understanding the tangled web of payer contracts, insurance rules and regulations can be time-consuming and overly complex. Keeping up with ever-changing reimbursement methodologies is resource-intensive for teams that are already suffering from staffing shortages. A system like Contract Manager and Contract Analysis can ease the pressure by streamlining workflows and showing revenue cycle management teams how payers are performing against agreed-upon terms. Contract Analysis seamlessly integrates with Contract Manager to provide all the data needed to make informed decisions about whether potential contract terms are in line with business goals – before any commitments are made. 2. Claims management software should help with error-free claims submissions In a perfect world, all claims would be completely accurate every time. But errors inevitably do creep in, leading to confusion, delays, and non-payments. Healthcare providers lose massive sums of money each year due to inaccurate claim submissions, denials, corrections, and rebilling. A good claims management strategy ensures that claims are error-free before they’re submitted. Claim Scrubber is an automated solution that reviews every line of each pre-claim and verifies that it is coded with the correct information before being sent to your claim’s clearinghouse. The result? Fewer undercharges and denials, optimized staff time and better cash flow. 3. Visibility of submitted claims With multiple steps, stakeholders, and milestones, keeping track of what’s happening with a claim can be cumbersome. Regardless of the workplace setting – individual hospital, large physician practice or a multi-facility Centralized Business Office – revenue cycle leaders need streamlined workflows, custom provider and payer edits, and superb customer support. ClaimSource is a solution that ensures all hospital and physician claims are clean before submission to government or commercial payers and creates custom workflows for easy prioritization and organization. With ClaimSource, providers can manage the entire claims cycle, from eligibility validation, claims editing, claims submission to the payers, claim submission reconciliation, remit retrieval, and reporting, in a single online application. 4. Claims management software should help prevent claims denials Denial rates vary widely between issuers. One 2020 study of HealthCare.gov issuers found that 1% to 57% of in-network claims were denied, while over 70% of major medical issuers had a claims denial rate of over 10%. Many reported denying one-third or more of all in-network claims. A tool such as Enhanced Claim Status makes it easy to respond early and accurately to denied, zero-pay, pending or returned-to-provider transactions before the Electronic Remittance Advice (ERA) and Explanation of Benefits (EOB) get processed. By removing the need for manual follow-up tasks and automatically submitting status updates based on each payer’s adjudication timeframe, providers can improve productivity and get paid the correct amounts faster. The claims management process is fraught with challenges. But with the right tools, data and analytics, these hurdles can be overcome. By integrating pre-claim (encounters) and post-claim (837) claims management software into the revenue cycle workflow, it's easy to review every line of every encounter. In this way, providers can verify that each claim is coded properly and contains the correct information before the claim is invoiced and submitted for reimbursement. Simply getting paid may not yet be as easy as providers would prefer, but technologies like Contract Manager and Contract Analysis, with their reliable customer support, can certainly oil the wheels. Find out more about how Experian Health’s Claims Management solutions with global payer edits and custom provider edits can help providers streamline the payment process and improve efficiencies, simplify the process and ensure speedy and accurate reimbursements.

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.

In the sixth article in our series on how the patient journey has evolved since the onset of COVID-19, we look at three ways to prevent claim denials and reduce the time to payment. Faster claims processing is at the heart of a better patient financial experience and reduces revenue leakage for providers. For more insights and strategic recommendations to improve the patient journey in 2021 and beyond, download the full white paper. Nearly seven in 10 healthcare leaders say claim denials have increased in 2021, with an average denial rate of 17%. Inefficient claims processing and claims management systems were already struggling, but the pressures of the pandemic are causing even more rejections. Vaccination programs, rescheduled electives, and residency relocations contributed to fluctuating patient volumes, putting extra strain on reimbursement workflows. Patients switching health plans, and missing codes for COVID-19 vaccinations and treatment caused further delays and errors. Payer rules for reimbursement of treatment for “Long Covid” remain unclear: the absence of research and standards means claims are rejected because there’s no agreed “medical necessity.” Slow processes, incorrect patient identities, and poor data management mean the upward trend in claim denials seen over the last five years shows that it is likely to continue. Denials create a fragmented experience for patients because they don’t know how much they’ll need to pay for care, and leaves providers battling to recoup revenue. An effective claims management system is critical for maintaining provider revenue, securing patient reimbursements, and promoting positive patient-provider relationships. Here, we recommend a three-part strategy that uses data and automation to get claims right the first time. Prevention is better than cure One of the primary frustrations for claims management teams is that the majority of denied claims are preventable. Many of the errors that trigger denials could be avoided if databases and records systems could talk to each other. Instead of a reactive response, providers should invest in tools that can proactively prevent mistakes and errors, to ensure they collect every dollar owed. Digital tools can analyze data to help providers weed out the vulnerabilities in their processes and keep up with payer changes. Incorporating such tools is a sensible first step toward reducing and recovering expenses. One option is ClaimSource, which helps ensure that all hospital and physician claims are clean before being submitted to a government or commercial payer. It unlocks access to extensive federal, state, and commercial payer edits, allows custom provider edits, and incorporates automation tools and customer support. Providers can become confident that their claims will be correct the first time. Improving the likelihood of approval is critical to provider profitability and makes for a smoother patient experience. Prioritize eligibility checks for cleaner claims the first time Experian Health’s revenue cycle management experts say that the number one reason for denials is inaccurate eligibility. A 2020 poll by the Medical Group Management Association (MGMA) backs this up: 42% of providers said inaccurate or incomplete prior authorizations were a top cause of denials. Most providers use a medical claims clearinghouse or have systems to check eligibility beforehand. However, if patient identities aren’t verified properly at every touchpoint in the healthcare journey, mistakes can creep in and cause confusion about eligibility. Similarly, if the patient needs additional treatment that isn’t covered in the initial authorization, the resulting mismatch could lead to a denial. Tools such as Prior Authorizations and Insurance Eligibility Verification can help providers validate patient coverage in under 30 seconds. These solutions integrate with ClaimSource to fill in the gaps of patient information and streamline the claims process. Patients will get better insights into what they owe, and providers can increase efficiency. Automate workflows to eliminate time-consuming errors with claims processing Providers are well aware that manual processing slows reimbursement and increases the risk of errors. Tools such as Prior Authorizations and Insurance Eligibility Verification can help by using data and automation to improve accuracy and efficiency. The Council for Affordable Quality Healthcare suggests that automation can shave 20% off claims processing times, which could translate to thousands of hours saved each month. With those extra hours, claims teams will be freed up to complete their lengthy to-do lists and focus their efforts on other priorities. In addition, automated workflows can help assign work to the right specialist, keep track of payer changes, and incorporate repeated identity verification checks to drive down denials. With a Denial Workflow Manager, providers can automate and optimize their entire denial management process to get real-time insights on denied claims. This system can eliminate manual reviews and quickly identify accounts for resubmission or appeal. It can be integrated with tools such as ClaimSource and Enhanced Claim Status, so providers can monitor claims, denials and remits on the same screen and accelerate the workflow. As the pandemic continues to pressure profits and patients come to expect more from their healthcare journey, it’s no longer reasonable to accept denials as a cost of doing business. To find out how Experian Health can help your organization reduce denials, recover pandemic losses, and improve the patient experience, contact our team today. Missed the other blogs in the series? Check them out: 4 data driven healthcare marketing strategies to re-engage patients after COVID-19 How 24/7 self-scheduling can improve the post-pandemic patient experience COVID-19 highlights an acute need for digital patient intake solutions Automated prior authorization: getting patients the approved care they need Getting a holistic picture of patients with social determinants of health

Rising medical debt, now a staggering $140 billion, is the largest source of debt for American families. A large portion of this is a direct result of surprise billing, with a third of insured adults saying they’ve received an unexpected bill in the previous two years. What’s no surprise, then, is that two-thirds of US adults worry about being able to afford these unanticipated medical bills. It’s a problem that concerns so many patients that it now has the attention and action of both state and federal governments. To help solve this problem, Congress signed the No Surprises Act into law. Experian Health can help your healthcare organization navigate the regulatory landscape  and implement solutions ranging from transparent, patient-friendly estimates to our all-new FREE No Surprises Act (NSA) Payer Alerts Portal.  The No Surprises Act, effective January 1st, 2022, aims to protect consumers from at least one contributor to the problem: unexpected bills for out-of-network care in emergency and non-emergency settings. Around a fifth of emergency claims and a sixth of in-network hospital stays include an out-of-network bill, often due to emergency or ancillary care. Since patients lack meaningful choices when it comes to choosing these unexpected services, they have no option but to pay up or face negative marks on their credit reports. Typically, while health plans cover some of the bills, patients will still be responsible for the remaining balances. Webinar Series: Unpacking The No Surprises Act and Q&A with an expert Industry expert Stanley Nachimson, Health IT Implementation Expert, recently hosted a series of webinars to help providers get up to speed on what they need to do to comply with the No Surprises Act. Learn about the Good Faith Estimate, how NSA will apply in different care settings, and more. By enforcing better price transparency and consumer protection, the new regulations will help to create better patient experiences and ensure that fewer bills are written off to bad debt. However, according to a recent survey conducted by Experian Health, only 72% of providers are familiar with the No Surprises Act. That’s not all - only 40% of respondents are moderately confident their organization will be able to solve for the No Surprises Act. Payers and providers must act now to ensure their processes are ready to comply with the changes. Experian Health is now offering a FREE comprehensive, updated list of No Surprises Act (NSA) payer policy alerts for United States hospitals, medical groups, and specialty healthcare service organizations. Tackling the price transparency problem with the No Surprises Act Healthcare pricing has been under the spotlight for a while, with several new regulatory measures introduced over the last few years. The new Act, which was signed into law under the Consolidated Appropriations Act of 2021, builds on previous federal actions to empower patients by giving them greater access to healthcare cost information. Come January 2022, balance billing will no longer be permitted for out-of-network emergency services, out-of-network air ambulance services, and out-of-network non-emergency services provided at in-network facilities. Insurers must cover emergency services without any prior authorization, regardless of whether the provider is within the health plan’s network, and patients should expect to pay the same as in-network services. The Act requires both providers and health plans to help patients access healthcare pricing information, and providers must provide consumers with tools to get better price estimates, including a “Good Faith Estimate” covering all relevant codes and charges. The Act sets out a process for health plans to reimburse providers and an arbitration path in the event of disagreement. Summary of provisions in the No Surprises Act: Protects patients from receiving surprise medical bills resulting from gaps in coverage for emergency services and certain services provided by out-of-network facilities Holds patients liable only for their in-network cost-sharing amounts, and requires that the patient’s share cannot exceed in-network rates without patient consent Provides guidance for how providers and insurers can negotiate fair reimbursement for out-of-network services Includes the requirements that providers submit Good Faith Estimates to payers and that payers utilize those estimates to create and provide Advance Explanation of Benefits to members. However, enforcement of this requirement has been delayed until more guidance can be provided related to standards for the transmission of these files (as of October 2021) What do providers need to do now to prepare? Creating a “no surprises” billing experience will require payers and providers to make major process changes. Roger Johnson, VP of Payer Solutions at Experian Health, says, “The new regulations require the industry to innovate significantly in a very short timeframe. Determining network status is a huge challenge for providers, as is engaging patients electronically pre-service. There will also be challenges in tracking and submitting consent forms, producing Good Faith Estimates, applying appropriate cost-sharing, billing, payment reconciliation, and the new dispute resolution process.” See what Roger had to say in our Interview with the Expert: CMS has provided a list of documents and requirements for patient notices. These include: A statement that the provider or facility is OON (if that is the case) An itemized, good faith estimate of the cost of care Information on prior authorization and utilization management limitations The notice must be in a format the patient can understand and is accessible (i.e., preferred language and apart from other documents). A variety of model forms and notices are available on the CMS “Overview of Rules and Fact Sheets” page: Standard notice & consent forms for nonparticipating providers & emergency facilities regarding consumer consent on balance billing protections: Download the Surprise Billing Protection Form Model disclosure notice on patient protections against surprise billing for providers, facilities, health plans and insurers: Download Patient Rights & Protections Against Surprise Medical Bills Paperwork Reduction Act (PRA) model notices and information collection requirements for the Federal Independent Dispute Resolution Process: Download Model Notices and Information Requirements Paperwork Reduction Act (PRA) model notices and information collection requirements for the good-faith estimate and patient-provider payment dispute resolution Download Model Notices and Information Requirements Additionally, The Department of Labor published a Model Notice link on its No Surprises Act overview page. Experian Health is engaging with industry partners to clarify the regulations and collaborate with clients to adapt workflows for a smooth transition. Find out more in our on-demand webinar. What price transparency tools are available for healthcare organizations?  In the meantime, various price transparency tools exist to help providers meet ongoing regulatory requirements and create a better patient experience with easy-to-understand cost breakdowns. For example: Patient Payment Estimates give patients clear and accurate estimates of authorized services before, or at, the point-of-service, so they feel more in control of their financial obligations. With a user-friendly interface, the tool helps patients plan and pay their bills – while directing them to appropriate financial assistance options. And because it’s automated, hospital staff will no longer need to manually update price lists. For providers, this tool can create an on-demand Good Faith Estimate using out-of-network benefits. Patient Financial Advisor is a text-to-mobile service that lets patients see their estimated costs of care before they come to the hospital. This solution provides a full breakdown of the procedures, as well as a total estimated amount based on in-network benefits. Registration Accelerator has the ability to collect provider forms and return them back to the client’s document imaging system. ClaimSource can identify claims that are at risk, prior to being submitted to payers. Claim Scrubber can identify claims at risk from various angles, such as: Non-Network payers Non-participating providers Services provided without an approved authorization Services provided outside of the approved authorization criteria While regulatory change can seem daunting, price transparency is already trending in the right direction. Our second State of Patient Access survey indicated that both patients and providers want more price transparency. Nine out of ten providers told us they agree that price transparency improves the customer experience and increases the likelihood that patient bills are paid. The regulations may be a catalyst for change, but making it easier for patients to understand and pay their bills continues to pick up momentum. That’s good news for patients’ wallets and for providers’ bottom lines. Download our on-demand webinar, "Unpacking the No Surprises Act," to learn more about how the new regulation will impact patient and provider workflows.

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.

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.