Tag: claims and contract management

Revenue cycle management (RCM) challenges exist at every stage of the patient journey – from patient intake and registration to insurance eligibility, claims processing and collections. Creating administrative efficiencies, reducing claims denials, improving the patient experience and remaining compliant with payer requirements and industry regulations all play a role in successfully managing revenue cycles and avoiding uncompensated care. This article takes a closer look at some of the top challenges in revenue cycle management, their root causes and strategies that leaders can use to tackle RCM issues head-on. Common challenges in revenue cycle management Staying on top of current RCM challenges helps healthcare organizations keep revenue cycles on track. Some of the key roadblocks in revenue cycle management include: Complex billing processes Health payer requirements change often and vary widely among the hundreds of providers operating in the U.S. To avoid delays and lost revenue, claims must be coded and billed correctly – the first time. However, a streamlined approach for error-free insurance eligibility verification, prior authorization and claims processing isn't always simple for healthcare organizations to implement and maintain. This leads to mistakes, wasted staff time and revenue loss. Rising claim denials Claims denials are rising, leaving healthcare organizations to face potential hits to the bottom from delayed or unpaid claims. Denials often occur when claims with incorrect patient information and billing codes are submitted. However, outdated manual processes, overburdened administrative staff and rapidly changing payer requirements can make it tricky for providers to manage the claims process efficiently and error-free consistently. Collections delays Collecting payments continues to be a major bottleneck in the revenue cycle, wasting valuable staff time and hurting provider bottom lines. With rising healthcare costs, a growing number of patients are struggling to pay their medical bills—especially when they don't know the cost of care up front or are self-paying. Estimates created with inaccurate benefits information or missing coverage add to patient and provider frustration and collection delays. Check out this guide to choosing the right key performance indicators for your revenue cycle dashboard to ensure the effective implementation of RCM strategies. Why these obstacles persist: Root causes of RCM issues Current roadblocks in revenue cycle management often persist due to the following root causes: Strained resources: Labor shortages continue to plague the healthcare industry – leaving revenue cycle managers tasked with figuring out how to “do more with less.” With staffing shortages expected through 2030, according to American Hospital Association data, maximizing staff time and administrative efficiencies must remain a top priority for the revenue cycle Lack of patient access: Some patients think patient access has improved, but there's still a long way to go. Data from Experian Health's State of Patient Access survey shows that 51% of patients feel patient access has remained static, despite 28% reporting an improvement since the previous year. High healthcare costs: Many patients struggle to afford healthcare thanks to climbing out-of-pocket costs, higher premiums and more complicated medical issues. As the cost of care and health insurance continue to rise, patients may be more likely to delay or default on payments. Medical expenses aren't likely to go down, leaving providers to help patients understand their financial responsibility and provide a simple path to payment. Frequent regulation changes: Legislation, like the No Surprises Act, plus ever-changing payer requirements, are time-consuming for busy administrative teams to monitor. Outdated patient intake processes and verification systems further contribute to compliance issues and resulting claims delays and denials. How healthy is your revenue cycle? Our revenue cycle management checklist helps healthcare organizations catch inefficiencies and find opportunities to boost cash flow. How to overcome revenue cycle management challenges The following strategies can help busy RCM leaders take steps toward creating a successful revenue cycle. Boost patient access Healthy revenue cycles begin with efficient and streamlined patient access. According to Experian Health data, 60% of patients say they want more digital options to engage with their provider and are willing to switch providers to get more digital access. Patients want it to be simple to book an appointment and complete intake paperwork – on their own time. They want to see their provider quickly, understand the cost of care and have the option to pay bills online or set up a payment plan. Adopting patient engagement solutions that improve access helps healthcare organizations foster more positive experiences, deliver better outcomes, collect more accurate patient data and increase their bottom lines. Providers can put patients in the driver's seat with tools that streamline scheduling, registration, estimates and payments. Staff is freed up from repetitive administrative tasks, patient no-shows decline, claims denials are reduced and collections are expedited. Improve claims management processes Processing claims is a significant contributing factor toward “wasted” healthcare dollars. According to Experian Health survey data, 73% of respondents agreed that claim denials are increasing, compared to 42% in 2022. Bad data is to blame, with providers saying incorrect information and authorization are driving the uptick in denials. 67% of respondents also agreed that reimbursement times were longer, indicating a broad issue with payer policy changes and claims errors. Revenue cycle managers who want to prevent denials, rather than just manage them, can reduce denials with automated claims management solutions. Tools like Experian Health's award-winning ClaimSource® make the claims editing and submission process effective and efficient. Other solutions, such as Claims Scrubber, help providers submit complete and accurate claims, resulting in more timely reimbursement and a healthier bottom line. In the case of denials, AI AdvantageTM - Denial Triage, uses artificial intelligence (AI) to identify denials with the highest potential for reimbursement, so that teams can focus on remits that have the most impact. Learn how Indiana University Health processed $632 million in claims transmissions in one week after a halt to operations. Keep pace with changing payer policies and healthcare regulatory and compliance standards According to Experian Health survey data, more than 75% of providers agree that payer policy changes are increasing. Staying up to speed on the ever-evolving compliance landscape is critical for RCM leaders who want to reduce claim denials, payment delays, and administrative backlogs. Digital regulatory solutions, like Insurance Eligibility Verification, can help providers keep up with evolving payer policies. Experian Health's price transparency solutions, like Patient Estimates and Patient Financial Advisor, allow healthcare organizations to remain compliant with regulatory requirements. Price transparency solutions provide proactive pricing information and make it easier for patients to pay, all while improving patient satisfaction. Nicole Ready, Revenue Cycle Systems Manager, at South Shore Health and Michael DiCarlo, Sr. Advisor, Revenue Cycle Operations at Northwell Health, discuss how they deliver better patient experiences with Experian Health's Price Transparency solutions. Preparing for new and evolving RCM hurdles Technology will continue to play a defining role in the future of revenue cycle management, for patients, providers and payers. Healthcare organizations can stay competitive by embracing AI and automation-based RCM solutions. From claims processing, verifying COB, MBI, and demographics in one click, prior authorizations to data analytics, RCM leaders can rely on AI and automation tools to optimize every stage of the revenue management cycle. Turning RCM roadblocks into opportunities for growth Revenue cycle management challenges are among the greatest obstacles facing today's healthcare organizations. However, improvements in digital tools and analytics can help providers keep revenue flowing while maintaining compliance and the patient experience in focus. With the right technology partner, RCM leaders can turn obstacles into growth opportunities. Experian Health's Revenue Cycle Management solutions can help your organization optimize revenue cycle management from patient intake to reimbursement. Learn more about how Experian Health's revenue cycle management solutions help healthcare organizations generate more revenue and increase their bottom lines. Learn more Contact us

Many healthcare providers believe pairing “revenue cycle” with a qualifier like “predictable” is an oxymoron. From healthcare staffing shortages that slow down reimbursement tasks to increasing payer denials, financial regularity can seem like an unattainable goal for these organizations.  The American Hospital Association (AHA) reports over one-half of U.S. hospitals had financial losses in 2022. Another AHA survey shows that 84% of these organizations say the cost of complying with complicated payer policies is climbing. Providers throw an excessive amount of time and staff at chasing revenue, but reimbursement complexities make for anything but smooth financial sailing. How can healthcare providers even out the ebbs and flows of the revenue cycle? Experian Health's suite of revenue cycle management (RCM) solutions can help. Revenue cycle predictability during the life of a claim When it comes to finances, U.S. healthcare providers rarely have an easy go of it. Today, the average life of a claim is anything but average. From registration to collections, hospitals established a new normal over the past decade: Widening gaps between service delivery and reimbursement. How can providers tackle this untenable situation? The answer is two-fold: with technology and at each stage of the life of a claim. Here are three ways healthcare providers can use technology to create reimbursement predictability at each stage of a claim's life. 1. Establish payment accountability at patient registration with price transparency Reimbursement problems begin at patient registration. Healthcare price transparency demands patients understand the cost of care. According to Experian Health's State of Patient Access survey, 81% of patients agreed that an accurate estimate helps them better prepare to pay for their care costs. However, only 31% of patients received a cost estimate before care. There are three significant impacts of this troubling trend: Nearly 40% of patients say they put off needed care due to cost. The number rises to 61% if the patient is uninsured. Patients can't afford to pay for needed care. Currently, 41% of U.S. adults have medical debt. An Experian Health study showed four in 10 patients spend more than they can afford on healthcare treatment. Uncompensated care causes a significant drop in healthcare provider income, which has amounted to almost $745 billion, according to the AHA. Experian Health offers several data-driven solutions to improve price transparency. These tools make it easier for patients to handle their financial responsibilities while helping providers find solutions to help ease their burdens.Patient Financial Advisor creates more accurate service estimates for patients before their procedure. The mobile-first platform offers patients a detailed cost breakdown on their preferred digital device. Patient Estimates is a web-based platform offering real-time service estimates. Blessing Health System uses the tool to provide patient estimates that are up to 90% accurate. The provider increased collections by 58% and credits the software with a 1,200% return on their investment. Patient Access Curator automatically initiates communication with payers to improve coordination of benefits and maximize return. It also automatically identifies missing or incorrect Medicare Beneficiary Identifier (MBI) numbers or errors in patient contact details. This solution also helps providers understand the patient's ability and propensity to pay, allowing these organizations to predict revenue streams after service delivery. Behind the scenes, Experian Health also automates insurance eligibility verification to unlock hidden reimbursements. This software roadmaps the correct coverage, connects to more than 900 payers and verifies insurance coverage at the time of service to improve cash flow and ease patient payment burdens. 2. Reduce claim denials by decreasing manual paperwork errors Claim denials are one of the biggest impediments to revenue cycle predictability. Providers are stuck in an endless cycle of inaccurate payer submissions, rejected claims, and rebilling, creating a chaotic chase for payment long after the service. Today, 35% of healthcare organizations report $50 million or higher in lost revenue due to claims denials. Even worse, Experian Health's State of Claims 2022 report showed that 30% of providers say denials are increasing by up to 15%. According to that data, the top three reasons for claim denials are: Missing or incomplete prior authorizations. Failure to verify provider eligibility. Coding inaccuracies. Experian Health's Claim Scrubber software levels out provider cash flow, creating predictability amidst the chaos. The solution reviews complete claims for errors, generating actionable edits before submission. Claim Scrubber also reviews approved reimbursement rates to prevent undercharging. Transactions process within three seconds and providers reduce the need to rework claims. Experian Health's AI Advantage solution uses the power of artificial intelligence (AI) to evaluate every claim for its propensity to turn into a denial. Instead of submitting claims and hoping the payer will accept them, this solution takes the guesswork out of reimbursement for a more rational, predictable process. The software automatically scans for payer updates to reimbursement requirements that significantly contribute to claims denials. Hospitals like Schneck Medical Center use this tool to streamline the revenue cycle by preventing denials. After just six months, the provider’s denied claims reduced by an average of 4.6% each month. Claim corrections that took up to 15 minutes manually are now processed in less than five. 3. Increase collections efficiency with automation Patients trust their healthcare providers to take care of them. Providers also rely on patients to pay their bills. It's a mutually beneficial arrangement. However, it's also a problem forcing providers to walk a delicate tightrope between caring for a sick patient while still chasing payment for their services. Unfortunately, the increasing cost of healthcare leaves patients on the hook for more than $88 billion in debt. The volume of healthcare payments in arrears is staggering, causing a substantial drain on provider cash on hand. However, technology offers healthcare providers a way to improve the patient collections process. For example, Coverage Discovery impacts the revenue cycle at every stage of the claim: Before providing care, the software scans patient data to determine reimbursement coverage options from Medicaid, Medicare, and commercial insurance. It scans for active insurance 30, 60, and 90 days after care delivery. The tool scans patient data before determining whether the account moves to bad debt collections. A more robust understanding of patient payment options at every stage of claims management allows healthcare providers to forecast reimbursements more accurately, increasing the predictability of the revenue cycle. Collections Optimization Manager provides organizations with actionable insights, so that providers can segment and prioritize accounts by proprensity to pay. This solution increases patient collections by leveraging Experian's data driven segmentation models, and helps providers screen out bankruptcies, deceased accounts, Medicaid and other charity eligibility ahead of time. Experian Health's AI Advantage – Denial Triage prioritizes rejected claims based on their yield potential, automating workflows for claims managers so they focus first on the patients more likely to pay. This tool segments denials based on their potential value to help even out the revenue cycle with a faster rate of financial return. Denial Triage expedites A/R by increasing revenue collection per person per hour. Revenue cycles can be more predictable, but the complexities of reimbursement require technology to achieve this goal. Experian Health offers a comprehensive line of revenue cycle management solutions to help healthcare providers maximize collections and improve RCM. Find out why Experian Health ranks Best in KLAS for 2024 in the categories of Claims Management & Clearinghouse and Revenue Cycle: Contract Management, or contact us for a more predictable revenue cycle, better cash flow, and a healthier organization.

Contracts govern the revenue cycle, but negotiating contracts and ensuring compliance can feel increasingly unmanageable as mergers and acquisitions, ongoing staffing challenges, and the sheer volume of contracts, plans, and provisions make contract management a massive project for healthcare providers. Tricia Ibrahim, Director of Product Management at Experian Health, shares her insights on a challenging environment heading into 2024. Providers are grappling with mounting complexity, an explosion of data, and continuing pressure to maximize efficiency and revenue. But, according to Ibrahim, healthcare contract management software is evolving to meet these challenges—and helping providers find clarity amid the complication. Q1: What are the major challenges with healthcare contract management as we move into 2024? “I think what clients are most concerned with, especially leading into 2024, is the complexity of payer contracts,” says Ibrahim. A typical provider may manage hundreds or thousands of contracts, each one with a range of plans and provisions that affect the bottom line. “Being able to negotiate better contracts is a key concern,” says Ibrahim, “but clients increasingly feel outgunned and overwhelmed by the amount of information involved.” Accessing and analyzing data effectively is more critical than ever. “When providers come together with payers to negotiate contracts, it can be difficult for them to evaluate the contract that the payer is putting in front of them,” in part because it's hard to know how their current contract is performing or how contract provisions will play out in dollars and cents, Ibrahim explains. “Underpayments and denials are a constant struggle. Also, providers need to understand how volume and patient mix will factor in.” Contract management has a direct effect on revenue and the bottom line. Negotiated terms may or may not cover actual costs. A small change in terms might have an outsized effect due to high volume. Denied claims, underpayments, downcoding and late payments can slow the revenue cycle and reduce the amount of revenue providers receive. “At the same time, we're also starting to see a greater interest in collaboration between providers and payers,” says Ibrahim. “Having additional visibility allows both parties to have more meaningful discussions and move toward solutions that work for everyone.” Q2: What are providers doing to take on these challenges? “Many providers are investing in technology,” says Ibrahim. “A 2023 analysis by Bain & Company found that 80% of healthcare executives had accelerated software and IT investment over the past year in response to mergers and acquisitions, staffing shortfalls, and an increasing need for efficiency.” As contract management becomes more complex, providers are also reaching for more powerful healthcare contract management software tools to manage data—and leverage it to negotiate contracts effectively and monitor contract compliance over time. Q3: How can healthcare contract management software like Experian Health's Contract Manager and Contract Analysis help providers negotiate better contracts? “Having meaningful information backed by data changes the dynamic,” Ibrahim says. “It allows you to have a more strategic conversation. You can say, 'You're supposed to pay us 45 days from the receipt of the claim, but it's been taking 140 days.'” Data provides objective information and can point the way toward measurable improvements going forward. “Our Contract Analysis module allows for the provider to audit payer contract performance,” says Ibrahim. That's not only helpful for tracking what's happened to date; it's also useful for projecting how a new contract might work going forward. “We're able to use historical claims to create scenarios that show how a new contract would affect payment. Sometimes, payers will keep reimbursement rates the same where you have a lot of volume and give you an increase where you don't. When you use our solution to run these types of analyses, you get a more effective understanding of proposed terms.” Q4: Once contracts are in place, how can healthcare contract management software help providers improve compliance? “Detailed analysis is key, and small discrepancies can have a significant impact,” says Ibrahim. “One of our clients, a large academic provider on the medical group side, spotted a trend where they were being underpaid by 10 cents to 50 cents on their EKGs. These kinds of variances typically go unnoticed, but they found 20 or 30 claims to submit.” The payer acknowledged the underpayment and issued the few dollars' difference. “Then the provider decided to look at their contract to see how far back they could appeal. It turned out they were able to go back a significant amount of time. When they added up the underpayments, it equated to $850,000. They ended up settling for $750,000,” Ibrahim says. OrthoTennessee, a Knoxville-based orthopedic practice with multiple locations and more than 50 physicians, uses Experian Health's Contract Management software for healthcare to find inaccuracies, make appeals, and audit contracts at scale. Using Experian Health's Contract Management platform, OrthoTennessee had an 86% success rate for appeals in 2022. “That's the power of the solution: You can really identify trends,” says Ibrahim. Monitoring compliance is a continuous effort: “We’ve done a lot of work with our clients to understand what their evolving needs are. We’ve been named Best in KLAS [by healthcare IT research firm KLAS] multiple years in a row. That recognition has centered around engagement—being engaged with our clients, so we understand what the trends are, what challenges they’re facing, and how we can help solve problems in the most efficient manner.” Q5: What role do regulations play in shaping contract management solutions? “Regulation drives different reimbursement methodologies, [such as] bundled payments or value-based care,” says Ibrahim. “Part of our challenge is making sure we are always evaluating new regulations and ensuring that our system is agile enough to support these new methodologies. “Because regulation never stops, it actually drives a lot of the innovation we do. The No Surprises Act, which came into effect in 2021, requires providers to provide patients with a good faith estimate of costs. We've been able to help clients establish an estimated median rate, which can be useful for estimates that involve non-contracted payers.” As an additional benefit, healthcare contract management software also helps providers spot opportunities. “One of our clients identified 26 plans with enough volume to support additional contracts,” says Ibrahim.  “Providers can even use these solutions to evaluate whether a market exists for a new piece of technology to deliver state-of-the-art care. Understanding performance is a powerful tool.” Q6: Early in our conversation, you said there was a growing interest in collaboration among providers and payers. What does it mean to take a collaborative approach in this context? “I think it's really important for providers and payers to have collaborative communication, to engage in productive conversations where they can work together instead of against each other,” says Ibrahim. “That's how we're going to deliver more integrative care and reduce costs. It’s how we’re going to arrive at coverage options that work for all parties, by developing good relationships between providers and payers. “For our part, Experian Health is continuing to expand Contract Manager to provide data analytics that clearly show the cost of care and the expected reimbursement for various types of services, so providers can evaluate contract performance, identify potential areas of improvement, and have meaningful conversations with payers. “At the end of the day, we all have a common goal: delivering appropriate care at the right time for patients,” Ibrahim concludes. “To progress toward that goal, payers, providers and partners like Experian Health are going need to work together.” These conversations start with a common set of data, so that everyone at the table understands where the opportunities to collaborate and improve may lie—and where the path forward may begin. Learn more about Experian Health's Healthcare Contract Management software and how it can help your organization negotiate and manage contracts effectively and efficiently, even in an increasingly complex environment.

Experian Health ranked #1 in Best In KLAS for our ClaimSource® claims management system and Contract Manager and Analysis product – for the second consecutive year. The rankings were revealed in the annual 2024 Best in KLAS Awards – Software and Services, published on February 7, 2024. The Awards recognize the top software and services vendors that are helping American healthcare professionals deliver the best possible patient care, based on feedback from thousands of providers. Experian Health topped the list in two categories: ClaimSource ranked #1 in Claims Management and Clearinghouse. This automated and scalable solution reduces denials and increases revenue through a single application. The addition of an artificial intelligence component this year (AI AdvantageTM) is helping providers cut denial rates to just 4%, compared to an industry average of more than 10%. Contract Manager and Analysis ranked #1 in Revenue Cycle: Contract Management. This product levels the playing field with payers by monitoring compliance with contract terms and recovering underpayments. It also arms providers with financial models of proposed contracts, so they can negotiate more favorable terms. Case study: See how Hattiesburg Clinic in Mississippi uses ClaimSource to automate claims management and reduce denials. The awards come as the industry grapples with ongoing staffing challenges and rising claim denials. In Experian Health's 2023 report on the healthcare staffing crisis, 100% of respondents saw staffing shortages affect revenue cycle management and patient engagement. As the pressure continues, revenue cycle technology offers a way to increase efficiency and improve financial performance.  “Healthcare professionals face immense pressures, ranging from financial strains to staffing shortages and the very real issue of clinician burnout,” says Adam Gale, CEO and Founder of KLAS Research. “We want to provide actionable insights that will ultimately alleviate burdens and enhance clinician success.” For Tom Cox, President of Experian Health, the awards reflect a continuing commitment to help providers optimize operations and patient engagement using data-driven insights and technology. “This recognition from KLAS recognizes our dedication to deliver innovative solutions that not only improve the financial health of providers but also the patient experience. Receiving this award two years in a row is an honor as we remain steadfast in our commitment to simplifying healthcare through technology.” Find out more about how ClaimSource and Contract Manager and Contract Analysis helps healthcare organizations increase efficiency and boost financial performance.

Getting a claim right the first time is much less expensive than reworking it. Experian Health's 2022 State of Claims survey illustrates most claims denials result from simple human errors. Automation and claim scrubbing software help lower the burden of denied claims. But payer contract management software offers one of the most critical strategies for optimizing revenue cycle. These tools help providers maximize reimbursements throughout the lifecycle of their payer contracts.   Experian Health client OrthoTennessee, which has an 86% successful appeals rate, recovers hundreds of thousands of dollars annually by conducting contract audits and recovering underpayments with these tools. This result could extrapolate across healthcare if providers consider implementing payer contract management software.  Understanding the financial impact of denial rates Denial rates can significantly affect a healthcare provider's revenue. One study showed these administrative complexities cause $265 billion in healthcare misspending annually. Preventing claims denials should be a high-priority issue for healthcare providers. It's an untenable situation for cash-strapped healthcare providers, and by most accounts, the problem is getting worse.  Payer contract management software reduces denial rates. A well-managed contract ensures providers are reimbursed accurately and promptly, reducing denials due to billing errors or non-compliance. Individual payer contracts stipulate how and how much a healthcare provider gets paid. In addition to critical payment terms, payer contracts contain:  How many days a provider has to submit a claim  How many days the payer will take to reimburse a correctly submitted claim  The services and scope of coverage by payer  Reimbursement rates for every covered service  How to dispute a claim denial  The term of the payer contract  When to renegotiate or the notice period for a contract termination Most of these reimbursement contracts allow payer amendments. Tricia Ibrahim, Director of Product Management, Contract Manager Suite, says, “Depending on how the contract is written, providers may receive very little notice of these changes. Without a way to systematically and efficiently monitor these agreements throughout the contract term, there is simply no way for a provider to ensure they're paid properly.” Better payer contract management can reduce denials and improve revenue collection by reducing the most common reasons for medical claim denials.  Proactive strategies for denial reduction Proactive denial reduction correlates with a better bottom line. This effort entails a multi-faceted approach with two key elements at its core: Analyzing payer contracts for pitfalls To mitigate denials effectively, healthcare providers must scrutinize payer contracts meticulously. By delving into the fine print, organizations can identify potential pitfalls and the sources of denials. Whether complex reimbursement terms, ambiguous language, or stringent coding requirements, a comprehensive contract analysis can unveil these challenges. Crafting contract strategies for denial mitigation With a deep understanding of contract nuances, providers can develop tailored strategies for denial mitigation. These strategies encompass streamlined claims submission and staff training. Additionally, organizations can engage in informed negotiations with payers to amend unfavorable reimbursement terms.  Through this fusion of contract analysis and proactive strategy development, providers can navigate the complex landscape of healthcare payer contracting with precision, ultimately reducing denials and bolstering financial stability.  Crafting comprehensive contract management strategies for denial mitigation Developing proactive strategies within payer contract management is a critical component of denial reduction.   For example, when creating payer contracts in healthcare, providers must proactively negotiate advantageous terms for their organization. These negotiations should focus on fair reimbursement rates, reasonable timeframes for claims submission, and other favorable conditions that minimize the potential for denials.  Strategies should also encompass addressing ambiguities in healthcare payer contracting. These misunderstandings lead to disputes and denials. Clarifying any vague or unclear language within the agreement ensures all parties have a shared understanding of the terms and expectations.  Finally, to mitigate denials effectively, healthcare payer contracts should align seamlessly with billing and coding practices. These contracts must reflect current industry standards and guidelines to prevent discrepancies resulting in claim rejections. Harnessing the power of payer contract management software in healthcare  Payer contract management software offers healthcare providers a powerful way to automate payer document analysis. A single provider can have 20 or more payer contracts to manage. From HMOs to PPOs, fee-for-service federal programs, third-party administrators, to ACOs and CINs—the payer list can be long. While a thorough analysis of healthcare payer contracting is essential to identify potential areas of improvement, it can be challenging to scrutinize all of these contract terms and conditions to mitigate future denial risks. But with the right software, this revenue cycle function can be a game-changer.  Payer contract management software can handle contract renewal and regulatory updates automatically, ensuring healthcare providers remain compliant. The software eliminates the hours spent manually reviewing data. Some of the benefits include:  Centralizing contracts in one location  Alerting significant milestones, such as contract renewals or changes  Automating processes and workflows  Linking contracts with provider procedures and complianc OrthoTennessee Manager of Payer Strategy, Frances Thomas, uses Experian Health's payer contract management software. She states, “The system gives us the information we need to be successful. They can't really argue with you on that.”  The role of automation in error reduction  Healthcare runs on revenue. Automation is pivotal for reducing healthcare claims errors that tie up revenue in the denials process. Automation software streamlines workflows, reducing manual intervention and the likelihood of human errors. These tools can apply across the revenue cycle, including during the payer contract management process. For example, Experian Health's payer contract management software includes Contract Manager and Contract Analysis features that can automatically:  Compare the expected payment with the actual reimbursement from payors  Maintain and manage contract terms  Pinpoint underpayments  Audit claims   Analyze claims data and the financial impact of potential changes to provider fee schedules  Highlight bulk claims for appeal en masse   OrthoTennessee highlights the importance of the ability to handle claims in bulk. Thomas says, “We had over 600 claims for one day in the wrong network. I was able to take that bulk of claims and handle those—otherwise, I was going to have to sit there and go claim by claim. It's a huge time saver to work smarter, not harder.”  Real-time verification and validation with automation Automated systems revolutionize healthcare operations by offering real-time verification and validation capabilities. Automation technology streamlines the billing process and minimizes errors that can lead to claim denials. It enhances efficiency and precision, allowing healthcare staff to allocate more time to patient care. As providers embrace automation, they can expect increased accuracy and financial stability. RevCycleIntelligence estimates the healthcare industry could save nearly 41%, or nearly $25 billion, of the $60 billion they spend annually by fully automating administrative transactions. But payers also stand to benefit; McKinsey says administrative automation could shave 30% off insurance claims processing costs.  Seamless integration of automation with payer contracts  Integrating automation tools with payer contracts in healthcare enhances efficiency. Integration ensures contract terms are consistently applied throughout the claims lifecycle, reducing denials. Interoperability between these platforms also improves the payer-provider relationship by increasing communication and streamlining processes.   Cross-platform integration creates two-way accountability that's a win/win for both provider and payer. It's a transformative step in healthcare revenue cycle management that could:  Streamline claims submission, verification, and adjudication  Continuously monitor claims for contract adherence and correct problems before they lead to denials  Reduce human errors  Apply advanced analytics to identify trends and patterns   Improve contract negotiations with data-driven decision-making  Lower administrative costs  Navigating challenges and embracing payer contract management software Healthcare providers face numerous challenges in revenue cycle management, especially when handling intricate payer contracts and the need for standardized handling of these documents. These challenges create scenarios where providers underbill or are underpaid for services, in addition to tying up revenue in denials management. Becker's Hospital Review reports providers lose up to 3% of their revenue from underpayments. Plus, the insurance industry isn't immune to making mistakes; the AMA says the claims processing error rate of public and private payers is more than 19%. By harnessing the power of technology, healthcare providers can streamline complex payer contracts and standardize how providers handle these agreements. For example:  To expedite negotiations, modeling tools within payer contract management software offer claim scenarios that help providers negotiate better rates from payers.  These systems provide real-time feedback through smart log messages, enhancing staff training and refining registration best practices.   Most healthcare organizations lack the time and resources to closely monitor payer contracts. When these agreements are on auto-renewal, it's easy to forget their importance. Payer contract management software helps these organizations wring the maximum amount out of these revenue streams. Embracing Experian Health's payer Contract Management software Experian Health's healthcare payer contract management software offers a comprehensive contract management solution that can substantially lower denial rates. By adopting this software, providers can maximize revenue potential and streamline their revenue cycle. Importantly, healthcare providers can implement payer contract management tools without adding staff or conducting major process improvements. This software is the one tool organizations need to ensure they don't leave revenue on the table. Learn more or contact us to speak to our experts.

Several major healthcare operators reported major losses for 2022, as revenue growth failed to outpace increasing expenses. McKinsey’s projections for provider profit pools suggest a more promising outlook over the next few years, with the fastest growth expected in virtual and non-acute care segments. As labor costs rise, organizations are looking for ways to cut spending and increase cash flow. Healthcare contract management is a key area to focus on, as underpayments and denied claims can significantly impact revenue. A third of providers report up to 15% of claims being denied, and underpayments continue to remain a significant concern. Securing reimbursements at already-agreed rates can help healthcare organizations significantly benefit financial performance. Unfortunately, managing payer contracts is not a straightforward process. Payer regulations and policies are in constant flux, and providers often lack the insights to negotiate and monitor payer performance effectively. Implementing a contract management solution can help providers negotiate favorable terms, check payer compliance, and reduce the risk of denials and underpayments. Why is healthcare contract management so challenging? Multiply thousands of vendors by thousands of service providers and again by thousands of patient encounters – and the scale of the healthcare contract management challenge becomes apparent. An average health system deals with hundreds of different payers, each with its own policies, processes, and paperwork. This lack of standardization makes it difficult to process claims efficiently and ensure payer compliance with agreed terms, not helped by soaring patient volumes and increasingly complex claims. The growing resource burden means the payer-provider relationship is coming under strain. But the challenge begins even before the contract is signed. Providers split their focus between numerous clinical and financial objectives. In contrast, payers can concentrate their attention more fully on fee negotiations. There’s an inherent imbalance in the resources each party brings to the negotiating table. As a result, providers are often on the back foot and can end up signing up for less favorable terms. Without a robust approach to negotiating and managing payer contracts, providers will struggle to achieve full reimbursement for services rendered. They may submit claims that do not adhere to payer policies, and find claims are being denied or not paid in full. More accounts will end up going to collections, and patients may be exposed to the threat of balance billing. At the extreme, providers may be forced to undergo lengthy appeals processes or even resort to legal action. The challenge of underpayment is especially fraught in emergency care, where disputes around reimbursement for services provided by out-of-network physicians at in-network facilities are common. It pays to invest in provider-payer relationships The solution lies in improving payer-provider relationships.. Smooth contract negotiations, clean claims and fair reimbursement rates are only possible when each party is clear about what they need from the other and delivers what they have agreed. By promoting better communication, transparency and accountability, providers can catch more underpayments and ensure more claims are clean the first time, leading to better financial performance. With a reliable contract management solution, providers can monitor payer compliance with contract terms and clarify what’s expected to ensure clean claims every time. Contract Manager and Contract Analysis: best in KLAS for healthcare contract management The 2023 Best in KLAS report identified Experian Health’s Contract Manager and Contract Analysis products as #1 in Revenue Cycle, Contract Management. This solution leverages Experian’s data, analytics, and technology to help hospitals and health systems improve contract management and financial performance in three ways: 1. Validating reimbursement accuracy Contract Manager helps providers find inconsistencies between amounts claimed and amounts paid. It accurately adjudicates each claim and compares expected payments to actual reimbursements. By continuously monitoring payer compliance with agreed contract terms, the tool identifies patterns of non-reimbursement to improve denial prevention and avoid missed revenue opportunities. Administrators can monitor reimbursement using online dashboards and real-time variance reports, which make it easy to manage multiple payer contracts and reimbursement methodologies. The tool also defines specific contract terms and fee schedules and can adapt to changing payer policies, to ensure that claims are processed and valued in line with current payment rules. 2. Preventing and recovering underpayments One of the biggest advantages of automation is the ability to find patterns that a human eye might miss (or take longer to spot). Manual processes (often based on a patchwork of Excel spreadsheets) are not only labor-intensive and costly, but do not consistently identify payment errors. Contract Manager offers a standardized approach to underpayment analysis, identifying sources and patterns of errors so recurring issues can be avoided in the future. Administrators can also use Contract Manager to generate data to support contract-based appeals, so they know which claims to appeal and can communicate more effectively with payers. 3. Negotiating favorable terms with payers Contract Manager’s automated system enables better management of collections data, payer performance and under-or over-payments. This puts providers in a stronger negotiating position when modeling new and amended contracts – a process that can be further improved with Contract Analysis. Contract Analysis assesses the potential financial impact of proposed contract terms down to individual service lines so providers can tailor their negotiation strategy to maximize reimbursement. It arms providers with real-world “what if” scenarios to provide insight into how contract terms could affect cash flow before they sign on the dotted line. Using real claims data to evaluate payer proposals gives providers insight into the true impact of proposed terms on reimbursement. It accelerates the negotiation process and gives providers leverage with payers that they might not otherwise have. Since the responsibility for proving that a claim has been wrongly denied or underpaid lies with the provider, it is on providers to make sure that agreed terms are favorable and to understand how they will ensure compliance. With Contract Analysis, they can reduce contract risks and prevent issues before they arise to drive down denials and underpayments. Using a healthcare contract management solution As the healthcare industry evolves, providers need to find ways to maintain resiliency and financial success. Healthcare contract management is an area where providers can make a significant impact on their financial performance. Unfortunately, managing payer contracts is a complex system with fluctuating regulations and policies. A dedicated contract management solution can help reimbursements maximize reimbursements and can provide the data insights providers need to efficiently negotiate better payment terms. Learn more about how Experian Health’s healthcare contract management solutions help providers improve contract negotiations, monitor payer compliance and recover more revenue.

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.

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

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.