Claims & Contract Management

Discover new integrated, intuitive, and technology-driven strategies to reduce claims denials and get paid in a timely and efficient manner.

Faster claims processing is crucial for better patient financial experiences and reduces revenue leakage for healthcare providers.

Learn how ACS worked with Experian Health and our Universal Identity Manager (UIM) platform to deliver the Experian Single Best Record (ESBR).

Product featured in this article: Coverage Discovery As of the end of March 2021, more than 53 million Americans have been fully vaccinated, allowing for cautious optimism as we prepare for the next phase of the COVID-19 journey. Unfortunately for pharmacists, the vaccination program has compounded many of the challenges of the last 12 months. Shots may be free to patients, but someone has to pay for them – and getting reimbursed is proving to be a major pain. Complicated billing processes, extra billing audits and mountains of extra paperwork, rejected claims and slow payments are not exclusive to pharmacies helping vaccinate America. With the coronavirus pandemic continuing to muddy the insurance landscape, getting hold of missing dollars is challenging. Healthcare reimbursements haven’t been straightforward for other providers either: widespread coverage loss and uncompensated care is putting extra strain on hospital revenue cycles. With the coronavirus pandemic continuing to muddy the insurance landscape, getting hold of missing dollars is challenging. Providers must find ways to quickly and accurately determine each patient’s coverage status to minimize bad debt. Navigating the complex world of post-COVID healthcare coverage What does the reimbursement landscape look like, one year on? After a long wait, elective procedures are back. But the surge in patient volumes means providers must be on their toes to keep track of coverage. The process for doing so must be streamlined and precise. Ramping up capacity to verify and check coverage without burdensome paperwork is a must. Patient intake is under pressure. More patients are coming through the doors as a result of elective services and vaccination programs (though not always to their usual facility). COVID-19 hasn’t gone away, and with pockets of infection spikes, safety remains a top priority. Capturing adequate insurance information in this context is no mean feat. Running automated coverage checks as soon as the patient arrives will minimize face-to-face contact during admissions and avoid delays. Patient access and collections staff are overburdened. Manual checks are difficult when staff are operating remotely or in a socially distanced environment, and patient information might be incomplete. Automated self-pay scrubbing can help handle the volume. A tool with built-in reporting can also offer insights on workflow and productivity, to help spot opportunities for quicker claims processing. New digital healthcare technologies aren’t always covered by insurers. Telehealth, a life raft during COVID-19, tends to be covered less often by private insurers, compared to Medicare and Medicaid. Coverage checks must factor this in to avoid errors and wasted time. Providers should opt for tools that sweep for payer updates to telehealth coverage to avoid unnecessary delays or denials. Employment levels may be inching upwards again, but tracking coverage remains a challenge as patients start new jobs with new health plans. In addition, checking for Medicare coverage in the midst of changing codes and protocols is time consuming and confusing. A third-party resource such as Coverage Discovery can look for all coverage options and make sure the right bill goes to the right payer. Find missing dollars with Coverage Discovery Hospitals, pharmacists and other healthcare providers can’t afford to continue losing money at a time when every dollar is needed to prepare for “after COVID-19.” Experian Health’s Coverage Discovery is a proven system for tracking down missing coverage quickly and easily, to avoid unnecessary revenue loss. Using billions of data assets and intelligent confidence scoring, it combs through multiple government and commercial payer accounts to maximize actionable coverage. Staff can trust the outputs and focus their attention where it’s really needed. By making coverage identification more efficient and accurate, it’s a shot in the arm for providers in need of faster reimbursements. Contact us to see how Coverage Discovery can be easily integrated into your revenue cycle, so you can maximize reimbursements over the coming weeks and months.

    Many thought the end of COVID-19 was in sight with the availability of a vaccine, and while that is somewhat true, an entirely new set of issues has arrived: how to properly administer and manage the vaccine. Now that a COVID-19 vaccine is approved and underway, providers need to execute a medical billing and coding strategy to sustain vaccination efforts. We interviewed J. Scott Milne, senior director of product management at Experian Health, about what’s changed and what providers can do to prepare. How can providers ensure that vaccine administration codes are billed correctly? The ICD-10 and CPT codes for the COVID-19 vaccine haven’t existed until now, which means providers have a new set of codes to learn and unfortunately, those codes seem to change or update almost daily. As more vaccines are introduced, more codes are also introduced, and not just for the vaccine as a whole, but for each specific dose of the vaccine. For example, dose one of the Pfizer vaccine will have a code that differs entirely from dose two of the Moderna vaccine. Keeping up with these changes isn’t only difficult for provider staff, who are likely already stretched thin, but they certainly don’t want to run the risk of submitting a claim with incorrect information. The errors are what result in denials or undercharges. A solution like Claim Scrubber ensures code sets are current on a daily basis – a necessity for times like these – but applies an extensive set of general and payer-specific edits before preparing the claim for processing. That means claims for vaccine administration are error-free before submission to the payer or clearinghouse. Providers can eliminate undercharges, boost first-time pass through rates and do away with costly, time-consuming rework. But proper coding is only the first piece of the billing puzzle. The second piece is to verify the accuracy of payment received from third-party payers. How can providers ensure that third party payers will reimburse at the contracted rates? Providers can certainly get reimbursed for administering the vaccine, but there are a lot of moving parts to keep up with. For example, both Medicaid and Medicare will reimburse providers for administering COVID-19 vaccines, but the percentage of what is covered will differ by carrier and the reimbursement rates can vary both by state and type of arrangement. Reimbursement rates will also vary amongst private payers. Then there is the variation in reimbursement based on vaccine type and dosage -- vaccines that require a single dose may be reimbursed at a rate different than those that require two doses. Even without the vaccine rollout underway it can be a headache for hospitals and health systems to manage multiple payer contracts and reimbursement methodologies. A solution like Contract Manager will pinpoint variance in reimbursement quickly and easily, accurately pricing claims and comparing actual allowed amounts to expected amounts. It is a tool built to adapt to changes within the industry, so providers can capitalize on emerging reimbursement schemes and changes in payer payment policies. It can also help identify sources and patterns of errors so recurring issues can be promptly resolved. The end result: the provider organization can the payer revenue that is due for vaccine administration. Interested in learning more about how providers can optimize vaccine-related reimbursements?     Other blog posts in this series: Segmenting your patient population for the COVID-19 vaccine Engaging patient segments with convenient, secure scheduling solutions Authenticating portal access with automation Optimizing reimbursements by capturing missing coverage

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.

The revised medical necessity form will be mandatory starting January 1, 2021. Here's what’s changed and what providers can do to prepare.

Halloween might be over, but healthcare fraud – or simple input errors – can transform a patient’s identity into something completely different. The negative impacts are potentially far-reaching, haunting both patients and providers. Is the patient standing in front of you really who they say they are? Learn more about Experian Health's identity management solutions and how we can help you match, manage and protect patient data with:  

Financial recovery after COVID-19 is likely to be a slow burn for most healthcare organizations, according to a recent survey. Nearly 90% of healthcare executives expect revenue to drop below pre-pandemic levels by the end of 2020, with one in five anticipating a hit greater than 30%. While the return of elective procedures will be a lifeline for many hospitals and health systems, the road to financial recovery remains fraught with obstacles: Five months of canceled and postponed procedures need to be rescheduled Worried patients must be reassured of hygiene measures, so they feel safe to attend appointments Patient intake and payment processes must be modified, in order to minimize face-to-face contact As the rate of infection continues to grow, providers must find new ways to also grow their revenue and protect against a further dent in profits. The healthcare industry is unlikely to see the recovery curve hoped for across the wider economy, but digital technology, automation and advanced data analytics could help provider finances to bounce back more quickly. 4 ways technology can accelerate your post-pandemic financial recovery 1. Easy and convenient patient scheduling unlocks your digital front door Patients want to reschedule appointments that were postponed or canceled over the last few months. To manage the backlog and minimize pressure on staff, consider using a digital patient scheduling platform, so patients can book their appointments online. A self-scheduling system that incorporates real-time scheduling and calendar reminders will help to create a positive consumer experience, while offering analytics and behind-the-scenes integration to keep your call center operations running smoothly. 2. Secure and convenient mobile technology can enhance your telehealth services Telehealth is the top choice for many hospitals looking to boost revenue growth and counter the impact of COVID-19, with two-thirds of executives expecting to use telehealth at least five times more than before the coronavirus hit. Many new digital tools and strategies designed to improve the patient journey as a whole can support telehealth delivery, and help to meet growing consumer demand for virtual care. For those beginning their telehealth journey, our COVID-19 Resource Center, which offers free access to telehealth payer policy alerts, may be the place to start. 3. A digital patient intake experience can lessen fears of exposure Although many providers are starting to open up for routine in-person appointments again, patients may wonder if it’s safe. Proactive communication about the measures in place to protect staff and patients will be essential. Another way to minimize concern is to allow as many patient intake tasks as possible to be completed online. Automating patient access through the patient portal can give patients quicker and more convenient ways to complete pre-registration, while contactless payment methods are a safe way to settle bills without setting foot in the provider’s office. 4. Optimize collections to bolster financial recoveryAutomation can also play a huge role in helping providers tighten up their revenue cycle, find new ways to enhance accounts receivable collections and avoid bad debt. Tools such as Coverage Discovery and Patient Financial Clearance enable providers to find missing or forgotten coverage, and help the patient manage any remaining balances in a sensitive and personalized way. Palo Pinto General Hospital uses automated coverage checks to find out whether a patient is eligible for charitable assistance within three seconds, so self-pay accounts can be directed to the most appropriate payment plan before the patient even comes in for treatment. With fewer accounts being written off, Palo Pinto has seen a noticeable improvement to their bottom line. The pandemic has been a wake-up call for an industry that has been traditionally slow to adopt new technologies. Ahead of a second wave of COVID-19, providers must move now to take advantage of automation and digital strategies to speed up financial recovery. Contact us to find out how we can help your organization use technology to improve the patient experience, increase efficiencies and kickstart your revenue cycle.