Navigating today’s dynamic healthcare billing and reimbursement climate can throw costly challenges at providers and their busy billing teams. Challenges like capturing accurate insurance data, timely claim submission, managing claim denials and rejections, handling review requests and audits. These issues and more contribute to reaching your number one goal of reducing days in A/R and getting more cash through the door.
In this post, we’ll break the reimbursement cycle down into three steps and show you how smart, simple changes to your processes arm you to tackle even the greatest challenges. In the next few weeks, we’ll dive deeper into strengthening these three key reimbursement stages so your team can bill well and prosper:
- Determining Eligibility
- Claims Submission
- Claims Management and Business Intelligence
Step 1: Eligibility Verification
Determining patient eligibility and coverage data is essential for successful claim acceptance rates and ultimately reimbursement from Medicare, Medicaid and commercial payers. Not only is front-end coverage determination critical, performing additional verification on reoccurring patients will help alert you to coverage changes that would otherwise cause claim adjudication challenges, including potential denials.
Up-Front Patient Eligibility Verification
Up-front patient eligibility verification lays the foundation for your entire revenue cycle process. Since eligibility errors create more reimbursement challenges than any other claim issue, the importance of this step cannot be overstated.
Because patient insurance information can change overnight, you may choose to verify eligibility when appointments are scheduled, again right before an appointment, at patient check-in and even after the appointment.
When determining eligibility, you should identify the following:
- Beneficiary and subscriber verification
- Eligibility and benefits
- Coverage type
- Deductible data
- Provider/service specific coverage information:
- Preventative services
- Cap or threshold amounts
- Hospice information
- PPS episode information
- Coverage changes since prior inquiry
If you’re still checking eligibility manually or if verification hinders your billing efforts, consider implementing eligibility technology that dramatically eases this step. Today’s technology allows you to accomplish instantly what once took significant effort to perform manually.
Many providers choose to retrieve patient eligibility data direct from the payer websites. This highly manual process costs you and your team time and money. This step becomes a must, however, because many eligibility providers don’t deliver the necessary data. You can eliminate this manual effort by choosing the right eligibility verification system. More advanced systems will automate the process of retrieving data directly from the payer websites, significantly enhancing the data you receive in your eligibility reporting. By capturing and comparing even more personal patient data and coverage information, advanced eligibility has the potential to exponentially improve workflow and output.
Identifying Coverage Changes
Tracking patient coverage changes requires a process to regularly check eligibility. Any provider who sees reoccurring patients will likely realize better reimbursement rates by performing monthly verification.
Regularly scheduled batch eligibility verification at the right time uncovers data that allows you to proactively reveal discrepancies in patient coverage.
Look for red flags like changes in Medicare Advantage Plan enrollment, deductibles, preventative services, prior episodes with another provider, etc.
During Medicare’s Open Enrollment period, it’s highly advantageous to run a batch submission including every patient you’ve seen the past 12 months to expose coverage changes that are costly if unnoticed.
Leveraging an eligibility technology vendor with automated change reporting capabilities will eliminate the hassle of manually sifting through heaps of patient data to detect eligibility changes. A vendor with advanced eligibility verification will report only those patients who show coverage changes.
Coverage discovery lets your front office team find patient eligibility for government and commercial coverage that may be missing or unknown during patient registration.
When patients lack coverage, oftentimes the unfortunate reality is they can’t pay. Adding an automated coverage discovery tool to your process boosts the chances of securing payment for care that may otherwise go uncompensated.
Adding an automated coverage discovery tool to your process boosts the chances of securing payment for care that may otherwise go uncompensated.
The payoff of a solid eligibility process is positive cash flow, less rejections and denials and a more efficient staff. Using a vendor like eSolutions for advanced eligibility improves workflow automation and reduces labor costs and days in A/R. Next, we’ll examine ways to improve your claims submission processes.
Step 2: Claims Submission
Now that we’ve showed you how improvements in patient eligibility verification set the foundation for your entire billing process, we’ll explore enhancing two key components in the claim submission process to ensure you’re submitting clean claims on time.
In the time between welcoming your patient for treatment and submitting their claim for payment, there’s vast room for error. Errors that lead to rejected or denied claims – like using the wrong ICD-10 code, invalid patient data, or incorrect dates of service. To handle claims submission, many providers turn to a clearinghouse that electronically scrubs the claim for errors, allowing providers to submit clean claims to payers on the first attempt.
Scrubbing optimizes the chances of quick and accurate reimbursement while dramatically reducing your labor costs by lowering the number of times you touch each claim.
Advanced clinical scrubbing further safeguards your claims by improving accuracy across thousands of coding and billing requirements, focusing on correct diagnosis and procedure codes. Most clearinghouses provide some basic clinical scrubbing, but superior clearinghouses should provide advanced clinical scrubbing.
Monitoring Timely Filing
The old saying “better late than never” doesn’t apply to claims submission. Late claims will result in denials and lost revenue.
Keeping track of multiple payers with different filing deadlines and guidelines can make your head spin. Managing timely filing of a re-billed claim is also vital.
A clearinghouse partner that tracks timely filing of your claims will prove to be a huge asset to your organization. Timely filing reports alert you to billed or re-billed claims in danger of being outside of timely filing guidelines. These features also allow you to easily spot any internal workflow and training errors preventing your claims from being filed on time.
Not all clearinghouses are created equal.
A truly advanced clearinghouse will provide features and benefits that go well beyond the traditional clearinghouse services. For instance, automated reporting and analysis of your claim adjudication data is tremendously beneficial to your organization. Look for a clearinghouse partner offering advanced claim edits, functionality and reporting capabilities. When choosing the right clearinghouse or switching clearinghouses, it’s essential to evaluate their payer network and the number of direct connections they maintain. Clearinghouses supporting a strong network of direct connections helps ensure claims reach the payers in a timely manner. You should also seek a clearinghouse solution that provides for cohesive integration with your other IT applications.
If you’re not using a clearinghouse, you’re missing the opportunity to streamline your workflow, touch claims less, reduce denials and rejections and get paid faster.
Step 3: Claims Management and Business Intelligence
So far in our Bill Well and Prosper post, 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 thousands of providers bill well and prosper for thriving businesses.