Tag: claims management

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.