Tag: claim denials

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.

The Appropriate Use Criteria (AUC) program is due to come into full effect in January 2023 at the earliest. The program was established by the Centers for Medicare and Medicaid Services (CMS) to help providers order the most appropriate diagnostic imaging services. Failure to comply may result in claims denials. Any provider that offers these services to Medicare beneficiaries should amend their clinical and revenue cycle workflows now, to avoid payment penalties when the AUC testing period comes to an end. This article sets out what providers can do to learn, test and prepare for the AUC program, and what Experian Health is doing to help healthcare providers manage these changes and minimize the risk of denied claims. What is the Appropriate Use Criteria program? The AUC program was created through the Protecting Access to Medicare Act of 2014 to help ensure that diagnostic imaging services would only be provided where medically necessary. No one would argue against evidence-based care. However, accessing that evidence can be challenging. Easy-access online tools are intended to make this easier. They have also been shown to reduce the overutilization of high-risk, high-cost imaging services. Under the program, any time a physician (or a member of their clinical staff) wants to order imaging services such as magnetic resonance imaging (MRI) or computed tomography (CT) for certain Medicare patients, they’ll need to consult an electronic Clinical Decision Support Mechanism (CDSM). This is especially important in an academic teaching environment. This online portal will check the patient’s electronic health record (EHR) and determine whether the order adheres to AUC or not, or whether the AUC consulted was not applicable. After consulting the CDSM, the ordering physician will need to include the following data on the order they send to the imaging services provider: the CDSM they consulted the ordering provider’s National Provider Identifier whether the service adhered to the applicable AUC or not, or whether no criteria in the CDSM were applicable to the patient’s clinical situation. Any ordering professionals deemed to be outliers will be required to seek prior authorization. When the program is fully implemented, imaging service providers will need to ensure they have a certificate of compliance to secure reimbursement. Who will be affected by the AUC program? The program applies to any provider that orders advanced diagnostic imaging services that are delivered in physician’s offices, hospital outpatient departments, ambulatory surgical centers (ASCs) or independent diagnostic testing facilities. It applies to those that are paid under the Medicare physician fee schedule, hospital outpatient prospective payment system or ASC payment system. It does not apply to Medicare Advantage beneficiaries. Emergencies, inpatient services and certain hardship exceptions are exempt. If any of these exceptions apply, the ordering physician must record them on the claim using the appropriate modifier code. When do providers need to implement it? CMS confirmed that there will be no payment consequences for failing to include AUC data until the later of January 2023 or the declared end of the COVID-19 public health emergency. In the meantime, providers are encouraged to implement the program on a voluntary basis, which will help identify pinch points in the claims management workflow. Claims submitted before full implementation may still be subject to denial, so it’s worth getting the process right now to avoid unnecessary rework later. How can providers “learn, test and prepare” for the AUC program? Healthcare organizations that may be affected by the AUC mandate should consider the following actions to ensure they are fully prepared by the time the program is fully implemented: Check the AUC program requirements and identify which service lines and vendors will be affected. Choose an appropriate Medicare-approved CDSM that closely matches existing EHR and claims management processes. Most EHR vendors will recommend a CDSM that fits seamlessly with their solution. CMS has also provided a list of certified CDSMs, which includes free options. However, these operate as stand-alone systems that will be more challenging to integrate with existing workflows. Communicate changes to staff. Ensure all referring and rendering providers are aware of and trained on the requirements and encourage dialogue to clarify new ways of working. Consider the impact on claims management teams, and ensure staff are trained on the new requirements. Healthcare Common Procedure Coding System G-codes and modifiers must be reported in claims alongside primary and secondary diagnosis and procedure codes. Are staff aware of the new codes? Are additional staff needed to process claims and potential rework that may be required after the AUC program is implemented? Build in time for review, to check that new processes are compliant. Ideally, the CDSM solution will include reporting functions to monitor progress and identify potential outliers that may be subject to prior authorizations later. If the furnishing provider is different from the ordering provider, the furnishing provider should have a workflow to confirm AUC adherence. How can digital tools and automation help providers ensure compliance with Appropriate Use Criteria? While the goal of the AUC program is to improve patient care and help manage the cost to the public purse, there will be an administrative burden for staff. The growing volume and complexity of claims overrule any attempt to manage this manually. Instead, healthcare organizations should look at automating the compliance process to ensure accuracy, prevent denied claims and reduce staff costs. To help healthcare providers manage these changes, Experian Health enhanced the Medical Necessity application to generate informational alerts when a procedure needs to adhere to AUC or prior authorization for Medicare patients. Users will be able to use this alert as a sign to check the AUC has been adhered to. These tools also fit well with Claim Scrubber, which reviews every line of each claim to verify that it’s coded correctly and isn’t missing any vital information, before being submitted. Claim Scrubber has also been enhanced to incorporate billing modifiers that will help with overall compliance requirements under the AUC rules. Preparing for what’s to come Access to medically necessary services is at the heart of evidence-based care. However, in promoting this, the Appropriate Use Criteria program creates additional tasks for staff that need to be understood and managed efficiently. While there are currently no penalties for non-compliance, providers should use the testing period to proactively implement new processes to determine their efficacy. As healthcare regulation continues to evolve, healthcare organizations should take a holistic approach to the exchange of information between clinical decision-makers, service providers and payers to lay the groundwork for consistent, accurate and reliable claims. Find out more about how Experian Health’s Medical Necessity and Claim Scrubber solutions support the claims management process and help healthcare organizations adhere to the Appropriate Use Criteria program.

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