Step 3: Claims Management and Business Intelligence
So far in our Bill Well and Prosper blog series, we’ve outlined ways to improve your eligibility and claims submission process for a thriving business. You’ve done everything to secure reimbursement by confirming eligibility and maximizing clean, timely claims submission. Now what? It’s time to manage your claims and embrace robust business intelligence to take your organization and cash flow up a notch.
Claims Management: Reporting Matters
Whether your staff manages claims or you use a vendor for this portion of your revenue cycle, successful claims management helps your organization reduce labor costs, avoid rejected and denied claims and reduce days in A/R.
Below are workflow automation reports eSolutions revenue cycle experts recommend for effective claims management.
Outstanding Claims Report: What we mean by outstanding claims are those you’ve submitted to payers that haven’t yet reached adjudication. This report identifies those claims pending adjudication it directly reflects how many dollars are in a hold status on which you may or may not be paid. It should also provide the number of days the claims have been outstanding. If a claim is outstanding for an alarming amount of time with no adjudication, you may need to follow up with your payer to find out why adjudication is delayed.
Oftentimes, payers such as Medicare require additional information on claims prior to adjudication. If you’re billing Medicare Part A (Institutional), it’s best to have an RTP productivity report showing you how many claims went into RTP and out of RTP, preferably in the last 30 days. Visibility into RTPs is advantageous for managers to measure workflow effectiveness.
Review Requests Reports: Payer claim review requests are just a fact of life. A system that automatically reports and tracks review requests and provides workflow direction is instrumental in claims management. This type of report maintains a detailed status on your review requests from the request date through adjudication. It should also present data to help eliminate any potential denied claims due to failing to respond in a timely manner.
Denied and At-Risk Claims Report: When a claim is denied, it’s critical you appeal the denial within the payer-specified time frame. If you fail to meet this timeline, you’re assured never to get paid. The Denied and At-Risk report flags denied claims that must be appealed soon. The report displays the date for submitting an appeal inside of the timely filing limits.
Business Intelligence: The Key to Prosperity
Many providers sit back and wait to learn the fate of claims without realizing the powerful data they can collect post-submission. Analyzing your claims and their outcomes lets you tweak fine details and identify root causes of issues from the front end of your cycle to the back end. Major benefits of business intelligence include:
- Reduced rejections and denials
- Decreased labor costs
- Less time spent working problematic claims
- Accelerated payments
Here are some impactful reports that provide proactive, game-changing data for truly informed decision-making.
Reason Code Classification Reporting:
It makes sense to classify reason codes into three different categories: Registration, Training and Coding.
By using these three broad classifications, providers can strategically identify portions of their business that warrant improvement.
Most often, registration errors happen due to eligibility issues, but it’s good practice to scrutinize your registration process for other types of errors. Training errors are common and are usually the easiest errors to avoid. By better understanding where your team could use additional coaching, you can dramatically improve your organization’s overall performance. Lastly, coding errors are bound to occur from time to time. Using technology that reports detailed coding error trends helps you quickly identify and correct the root cause of these errors. Allowing any of these common errors to continue unresolved will unnecessarily increase your labor costs, add A/R days and decrease cash flow. If you’d like more information on avoiding these types of billing mistakes, check out this recent blog post.
Top Rejected and Denied Reason Codes: This vital report shows you the top reason codes applied to rejected and denied claims. Payers reject and deny claims for a wide range of reasons — everything from coding errors, unallowable services, to billing the wrong payer. According to MGMA, the cost of working a denied claim is about $25 per claim, so understanding your rejected and denial codes empowers you to make decisive, proactive changes to your workflow. Whether the root cause is a training issue, system issue, or a process issue, the bottom line is clear – the better informed you are about these root causes, the easier it becomes to understand your rejections and denials and make changes to your systems and processes.
Downcoded Procedure Analysis: Payers sometimes change the procedure code you billed on a claim and pay you a lesser amount. It’s helpful to have a report highlighting any changed codes by the payer so you can ask your payer for an explanation and even request a payment adjustment.
Allowed Amount by Procedure Code: This report identifies the allowed amount of reimbursement by procedure code, providing the average dollar amount you were paid by procedure, by provider. This report also displays the number of claims you’ve billed by specific procedure code and the maximum and minimum amounts you’ve historically ever been reimbursed by specific payer for specific procedure. What’s the value in monitoring this information? First, it reduces the need for manually checking your reimbursement against the amount you contractually agreed upon with your payer for each procedure. Second, it’s a simple report that ensures you’re being properly paid. And third, it’s relevant to your overall business because you can determine if the procedures you provide are profitable or costly.
Benchmarking Reports: How do your billing and revenue cycle practices compare to other providers in your region? How do you compare nationally?
The capacity to compare your performance against peer groups and the industry is beneficial for developing best practices.
Even more advantageous is a solution that allows you to set your own reimbursement and business benchmarks.
Of course the key to prosperity is effectively using business intelligence and key indicators to streamline your reimbursement processes. If your organization has little or no reporting capabilities, start slowly so you’re not overwhelmed with too much information. If your organization uses reports, try stepping up your game with more insightful reporting that provides highly actionable data.
Now that you understand how smart, simple changes to your processes can transform your reimbursement, you can turn to a health information technology leader like eSolutions for best-in-class, web-based products that address each key revenue cycle stage. Our diverse market experience matched with our ability to integrate superior service with proven technology allows us to help providers of all types and sizes solve daily complex challenges. Find out how eSolutions helps more than 30,000 providers bill well and prosper for thriving businesses.