Tag: claims management

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.

Patient experience may not be the first consideration that comes to mind when you're looking to improve revenue cycle management (RCM). However, a positive patient experience can benefit RCM. It can make the complicated process of understanding and managing healthcare finances simpler and more seamless for patients—and facilitate an easy-to-navigate continuum of care that includes RCM. Financial transparency plays a significant role in building trust and confidence between patient and provider. Patients who may find it difficult to understand medical billing and health insurance coverage—and who are paying more out-of-pocket costs thanks to high-deductible health plans—appreciate accurate estimates and a range of convenient payment options. By optimizing back-end claims, billing, payment and collections processes, providers free up staff to provide individualized help to patients who need it. Strategies to bolster patient experience and RCM Patients who have grown accustomed to using digital platforms for everything from online shopping to food delivery, travel, managing finances and entertainment gravitate toward digital tools and expect a high level of functionality. In a Salesforce survey of 15,000 consumers, 68% of respondents said their expectations of companies' digital capabilities increased after COVID-19 drove more of their activity online. Providing a superior digital experience is now synonymous with good service, but healthcare is lagging behind other service sectors. For providers, automation and data analytics can streamline workflows and improve efficiencies. These factors are critical as staff find themselves under increasing pressure to provide accurate patient estimates upfront and to submit claims accurately to reduce denials. How can providers use the patient experience to improve RCM? Here are a few areas of focus to consider: 1. Offer consumer-friendly front-end technology Patients are looking for seamless digital experiences, where they are empowered to search out what they want, choose from a menu of options and pay effortlessly online. In a healthcare setting, they want to find and schedule their own appointments quickly. Providing new and existing patients with 24/7 mobile access to online patient scheduling is critical to early engagement. In fact, a new report from Experian Health and PYMNTS revealed that 61% of patients interested in using patient portals say they would switch to a healthcare provider that has one. Providing patients with an accurate estimate they can review in advance improves transparency and builds trust. This allows patients to ask questions and make decisions about how to pay on their own time and without pressure. Pre-appointment estimates might also offer patients the opportunity to pay conveniently online before their appointments or at the point of service, minimizing the need for post-treatment collections and reducing RCM costs. 2. Simplify and automate in-office technology Automation can boost the experience on both sides of the front desk. Automated processes simplify patient-facing tasks like registration and check-in while making back-office operations like data entry and authorizations more efficient. “When a patient submits photos of their insurance card and identification, software scrapes that information and inputs it into the system,” Serie explains. “This process is more convenient for the patient, faster and more efficient for staff, and reduces the potential for human error.” As healthcare providers continue to experience staffing shortages, automated systems can offer greater workplace flexibility. That's helpful for providers that need to flex their resources, but also for employees who want more options on where and when they work. 3. Provide price transparency and financial information to improve the patient experience In a Policygenius consumer survey, 26% of respondents said they have avoided care or treatment because they were unsure what their insurance covers. Patients might be forgiven for feeling confused and frustrated – healthcare bills are not always patient-centric. In fact, many consumers report a low level of insurance literacy and, unless told, don't know in advance what medical procedures are likely to cost. At the same time, out-of-pocket costs are rising, raising the stakes and increasing the likelihood that medical bills will pose a significant financial challenge. Outlining estimated costs prior to service can help patients understand their expected out-of-pocket payments. Accurate patient payment estimates take away some of the sticker shock and give patients an opportunity to discuss coverage with their insurance companies, choose the right payment methods, or arrange for payment plans before treatment happens. 4. Allow for online bill payments Frictionless payments are now the norm, online and in-app. Experian Health's PatientSimple solution offers healthcare organizations a suite of tools to simplify payment. Using a healthcare-specific algorithm, PatientSimple provides personalized, data-driven insights that help providers deliver the right messaging and payment options, including: Price estimates based on insurance coverage and payer's negotiated rates Guest payment option for patients who don't want to set up an account Online payments and payment plans E-statements, online account access and email payment reminders Qualification for financial assistance A smoother path to payment increases the chances that patients will pay pre-appointment or at the point of service. By offering patients more and better payment options providers can increase up-front revenue and reduce the need for collections. 5. Enable self-service Frictionless payments are just one facet of helping patients help themselves. Enabling the tools that create a “digital front door”—including the ability for patients to register and check-in online, access a virtual waiting room and make “contactless” payments—can boost engagement and give patients greater choice, control and convenience. By mapping a patient journey that flows seamlessly between virtual and in-person interactions, providers can set the stage for receiving payment earlier in the process. This can also help with outreach to patients post-care for follow-up and payment, if necessary. 6. Ensure coding and billing accuracy Clear, accurate patient billing is the goal, but keeping up with changes across multiple payers is an ongoing challenge for healthcare providers. New products, mergers and acquisitions, policy and procedure changes all create the potential for errors, denials, delay and lost revenue. Experian Health's Payer Alerts helps notify providers of payer policy and procedural changes with a daily digest email and an online portal. A simplified estimate process with fewer revisions streamlines the RCM process; it also helps patients avoid confusion, which degrades the patient experience and may cause patients to delay payment. 7. Optimize bill collections Collections can be one of the most difficult parts of healthcare RCM. On the patient side, post-treatment collections feel like a hassle; they may also become a source of significant financial problems. For providers, collections can be costly and time-consuming. Optimizing collections with automation and data analytics can streamline the process and improve outcomes. Experian Health's Collections Optimization Manager uses specialized scoring algorithms to segment and prioritizes accounts based on the likelihood they'll be able to pay. Automated billing and outreach make collections less onerous for staff, while automatic updates keep accounts and communications current. For patients, providing convenient digital payment options takes some of the friction out of the payment experience and removes at least one barrier to bringing an account current. Patient experience and RCM go hand in hand Improving healthcare RCM is certainly not the only reason to work on improving the patient experience. Enhancing the patient journey across the care spectrum can help providers engage new and existing patients, offer the digital tools and seamless experiences they've come to expect, and reduce their anxieties over medical costs. At the same time, using RCM solutions to bolster the patient experience means new efficiencies for staff and, along with this, expanded opportunities for work flexibility and greater success at managing the revenue cycle. Contact Experian Health to learn more about optimizing your patient experience and improving RCM at your organization.

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.

For many of the 36 million Americans who have registered for unemployment benefits during the coronavirus outbreak, losing their job means losing their health insurance. Options for the newly-unemployed are limited yet complicated: while the federal government has declined to reopen enrollment under the Affordable Care Act, several states are supporting those without coverage by opening emergency enrollment periods for state-based health exchanges. Those that can afford it may extend their existing employer plan through COBRA, while those that can’t may apply for Medicaid. But unfortunately, millions will be left without coverage. Now, with these changes happening in both large quantities and at rapid speed, the process for checking a patient’s coverage status is more complex, time-consuming and susceptible to errors than in normal circumstances. Further errors may appear as patients are forced to switch care teams, leading to disjointed care and incomplete, inaccurate or duplicate health records. It’s a huge administrative and financial burden for providers, who must keep pace with changes to the health insurance landscape or risk a surge in denied claims as a result of patient misidentification. How should they guard against patient identity errors and minimize revenue loss in the wake of COVID-19? How to prevent mismatched patient records and avoidable claims denials A 2018 survey found a third of denied healthcare claims were caused by patient identity errors, costing hospitals an average of $1.5 million. We may see this figure creep up following COVID-19, unless providers move quickly to implement robust identity proofing and patient matching processes. Providers looking to do this should consider prioritizing the following three areas: Eliminate errors during patient registration Up to half of denied claims occur earlier in the revenue cycle, which is also when most duplicate medical records are created. Improving identity proofing during patient scheduling and registration is a logical place to focus, to ensure records are accurate from the start. This should include proactively checking for active coverage as early as possible. Using a Coverage Discovery tool that automatically finds available coverage will help avoid bad debt write-offs and give patients peace of mind. Essentia Health’s Patient Access team were able to find 67% coverage pre-service, for patient accounts that were previously considered self-pay or uninsured. Automate identity matching throughout the revenue cycle When patient records are incomplete, duplicated or overlaid with part of someone else’s record, denied claims become an accepted cost – but they’re often avoidable. Instead of time-consuming and error-prone manual checks, providers should consider using automated identity management software to ensure patient records are accurate and complete. Data-driven matching technology supported by a Universal Patient Identifier allows a single view of each patient to be shared safely and securely across multiple healthcare services. There’s no need for tedious reconciliation work and providers can be confident they’re submitting clean claims each time. Improve identity management protocols for telehealth and mobile services More patients turning to telehealth services and patient portals to minimize face-to-face contact, putting pressure on providers to solve the patient matching problem. And with payers expanding coding for reimbursements for telehealth and remote services, there’s an added imperative to make sure patient information is accurate in order to minimize the risk of claims denials. Victoria Dames, Senior Product Director at Experian Health, says portal access has increased by roughly 40% since the start of the coronavirus outbreak, and explains that the rise in telehealth and mobile services means identity proofing must be a priority: “If you don’t already have identity proofing and automated solutions for patient matching in place, you’ll have duplicate records. We don’t want that – it’s important to have one view of the patient. But we need to move quickly. Automating for identity proofing eliminates the risk of human error and it’s faster too, which is crucial right now. We know many providers want to get their identity management and claims management systems optimized quickly, so we have a team set up to help.” Using the right technology to verify patient identities and analyze claims, avoidable denials resulting from missing or incorrect information can be caught sooner. Contact us to find out how we can help your organization manage patient identities to eliminate costly claims denials during and after COVID-19.

There is no doubt the healthcare industry has taken a financial beating as a result of COVID-19. But there is a glimmer of hope for providers. Several new announcements were recently made attached to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, specifically around reimbursements attached to COVID care for the uninsured. The financial stimulus, intended to stabilize hospital finances as providers face short-term revenue reductions due to the cessation of non-urgent procedures and the increased costs for personal protective equipment, has earmarked  a portion of the $100B established for CARES to reimburse healthcare providers at Medicare rates for the treatment of uninsured COVID patients. The guidance does not indicate specifically how much money will be set aside to reimburse these claims. The big question? How long will the funds last and how quickly will providers act? With both unemployment, translating into more uninsured individuals, and COVID cases on the rise, the dollars could be exhausted quickly. A recent study by Kaiser estimates the total payments to hospitals for treating uninsured patients under the Trump administration policy would range from $13.9B to $41.8B. While Medicare payments are about half of what private insurers pay on average for the same diagnoses, estimates surrounding COVID care can be in excess of $50k for those severe cases where struggling patients spend weeks in the intensive care unit on a ventilator. Bottom line, it’s likely the funds will be distributed quickly, especially when factoring in unemployment skyrocketing. As of April 30, more than 30M Americans have filed jobless claims amid the coronavirus outbreak. The all-new portal opened on April 27 for sign-ups, and providers can begin submitting claims electronically on May 6. Healthcare providers who have conducted COVID-19 testing of uninsured individuals or provided treatment to uninsured individuals with a COVID-19 diagnosis on or after February 4, 2020 can request claims reimbursement through the program electronically and will be reimbursed at Medicare rates, subject to available funding. A complete list of FAQs regarding the CARES Act and reimbursements are accessible on the Health Resources & Services Administration website. But what other tips and considerations should providers contemplate as they attempt to get their fair share? Here are three actions to optimize a provider’s chances of claiming reimbursements for the uninsured. Automate the insurance check. Providers must attest that they have checked for healthcare coverage eligibility and confirm the patient is uninsured. If they fail to check, they may be denied. Providers must verify that the patient does not have coverage such as individual, employer-sponsored, Medicare or Medicaid coverage, or any other payer options that will reimburse for the COVID-19 testing and/or care of that patient. There are ways to automate this step, completing a second eligibility check to attest that the patients have no coverage before providers submit claims to the government. Scan for the social security number (SSN), if possible. While there may be instances where COVID patients entered a facility and were quickly admitted with no formal registration process, the CARES Act states an SSN and state of residence, or state identification/driver's license is needed to verify patient eligibility. If these pieces of information are not captured, providers need to attest that they have attempted to capture this information before submitting a claim. The patient may be long gone, but there are still ways to attempt to retrieve a patient’s SSN after they have exited the healthcare facility. Providers should know that claims submitted without an SSN and state of residence, or state identification/driver's license may take longer to verify for patient eligibility. Again, with the possibility that these funds could quickly be exhausted, it is in the provider’s best interest to submit claims that are as clean and validated as possible. Act fast. Recall the Small Business Administration's Paycheck Protection Program (PPP) — a coronavirus relief fund for small businesses that was also established under CARES? The $350B allocated by the bill was quickly depleted in days. While these funds were going to individuals in entirely different industries, there is no concrete projections on how long healthcare providers can expect the $1B fund to cover reimbursements for the uninsured. So, providers need to act now, and fast, by tapping into automation and auditing solutions that will optimize their chances of securing their fair share.

In its first year of consideration, Experian Health’s ClaimSource® solution garnered the 2017 Category Leader title for claims management. This was achieved by having products and customer support that address the top issues in Patient Accounting, including: Declining reimbursement making it more important to ensure accurate payments Slow payment from third-party payers Having to make analytics-based key financial and operational decisions Constantly changing governmental mandates and payer requirements Managing the move from fee-for-service reimbursement to value-based reimbursement The challenge of finding skilled resources The continual stress to do more with less The Experian Health ClaimSource product suite addresses these challenges first by providing excellent products that are all seamlessly interfaced and can provide exception-based processing for: Automation of processing clean claims through the use of an expansive library of national payer edits The ability and willingness to create provider specific custom edits Expediting the follow up process thru the use of enhanced claims status detailed responses Enabling more efficient processing of denials by analyzing denials reasons and automating workflow Automating the payment posting process with customized posting files for handling splits and contractual adjustments Providing the best interfaces available for Epic clients for both hospital and physician billing offices We follow that up by offering superior customer support for our clients. By leveraging our size, experience, and multiple locations in Sacramento, California and our new location in Schaumburg, Illinois, we support clients from Hawaii to New York to Alaska to Florida and everywhere in-between. These two offices allow our clients to get great hands on support for implementations, training, extensive custom programming, as well as experienced billing analysts with decades of billing knowledge. We always thought our claims products stood out against our competition, but now KLAS has validated that for us. Ask your Experian Health account representative or email us at experianhealth@experian.com to find out how we can help your business office address your specific needs.