Tag: enhanced claim status
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