Category: For Hospitals & Physician Groups

Stay informed on the latest industry news, best practices, and trends in revenue cycle management for hospitals and physician groups.

Five Benefits Your Claim Clearinghouse Should Provide

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If you’re looking for ways to increase efficiency and improve cash flow for your hospital or practice, make sure you’re taking advantage of all the benefits of a claim clearinghouse. Far from being a simple middleman in the reimbursement process, a good clearinghouse partner will assist in driving down your days in A/R and improve your operational performance.
Consider these five key benefits your claim clearinghouse should provide:

1.    Interpreting ANSI and payer-specific claim requirements

Since ANSI 5010 was adopted in 2012, providers have needed to convert their claims into countless variations of the format to satisfy payer-specific requirements. When you employ a claim clearinghouse, this work is done for you. You submit your claims to the clearinghouse, and they translate the data according to the payers’ nuanced specifications. Not only will this improve your claim acceptance rate, but you’ll no longer be burdened with deciphering each payer’s ANSI companion guides yourself.
2.  A robust edit engine to produce cleaner claims for faster reimbursement

If you’re looking for a claim clearinghouse, you’re probably aiming to improve your first-pass clean claim rate—the percentage of claims that are accurately processed and reimbursed the first time they are submitted to the payer. To help you meet this goal, your clearinghouse should offer a powerful edit engine with the ability to customize edits by client, and a commitment to keeping edits current, documented, and supportable. A strong edit system will streamline your claims management process, reducing the need for manual intervention.
3.    Dedicated implementation, service, and support teams 
With any business relationship, you want superior customer service. The relationship you establish with a claim clearinghouse is no exception. A good clearinghouse will have specialized, knowledgeable support teams, including an implementation team to get new clients up and running quickly and efficiently; service representatives to provide on-site support; IT personnel to resolve your technical issues; and a transmissions support team to monitor your claim transmissions. This kind of service may be hard to find, but it’s an invaluable quality to look for in a clearinghouse. 
4.    State-of-the art claims management software with the ability to interface with your EHR
It’s important to find a clearinghouse that offers state-of-the-art claims management software so you can correct claims and configure edits with ease. One software service model that sets a clearinghouse apart from the rest is the ability to interface directly with your electronic health record (EHR). This allows you to leverage the clearinghouse’s powerful edit system while correcting claims with errors in your own EHR. With this kind of interface integration, you can expect a significant boost to the efficiency of your workflow.
5.    Managing the claims transmissions process
Whether you are a small practice or a large hospital system, your clearinghouse should be able to handle your daily claim transmissions. This includes coordinating the timing of transmissions with payers, monitoring transmissions, resolving issues, and providing you with documented results. Your clearinghouse should provide the technology and horsepower to make your claim transmissions process as seamless and hands-off as possible.

A claim clearinghouse that offers all five of these benefits will deliver the ultimate benefit you need: increased cash flow with decreased expense. Learn more about our Claims Management Solutions.

Is Your Claim Follow-Up Strategy Losing You Money?

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Ideally, claim follow-up should only be performed by your staff when taking action defends the reimbursement you deserve. Any action taken that does not directly improve your reimbursement or cash flow, erodes your profit margin by increasing costs without increasing revenue. One way to control follow-up costs is to use advance claim status to identify when claim follow-up makes “cents.”

The key is to know which claims would best benefit from follow-up.
It all begins with knowing where your claims are in your payers’ review process – assuming your claims made it to the payers’ review process.

Looking at the key stages of the payer’s review process, let’s identify when follow-up makes “cents” and when it doesn’t.

  • When the claim status is in-process, no follow-up action is recommended. The payer has not yet made a decision on the claim. At this time, it may be more cost-effective to wait. After a certain amount of time has elapsed, a second claim status inquiry can be made.
  • When the claim status is to-be-paid, no follow-up action is required. The payer has made a decision to pay the claim and a payment will be received. Any action taken by staff adds cost to confirmed reimbursement. Gaining insight that a claim is to-be-paid at the time of the payer’s internal decision (which may be much sooner than upon receipt of remittance advice), can help your staff avoid unnecessary follow-up.
  • When the claim (or line item) is denied, rejected, or pending, it is important the right follow-up action be performed in a timely, efficient manner. To identify the best course of action, it is critical to fully understand why the claim (or line item) has not been paid. Follow-up staff can target next steps and avoid the cost of trial-and-error issue management.

So how do you obtain claim status information? Labor intensive options include calling the payer or accessing the payer portal. Both options are high-cost, low-volume solutions that require manual processing. It is more cost effective to obtain your claim status responses electronically. According to a 2016 study by the CAQH Index,® switching to an electronic process for claim status inquiry can save up to $7.94 on the cost per transaction over manual processing representing an 81% savings. Though automated ANSI 276/277 claim status inquiries and responses provide some benefit, the problem is that payer ANSI responses tend to lack the more actionable data found in payer portals. It is generally the detailed proprietary payer codes and comments found in payer portals that offer the best source of information.

Here’s where Advanced Claim Status (ACS) by Quadax can help. Electronically scraping status information directly from payer portals using web-bot technology, ACS replaces or supplements standard ANSI 276/277 transactions to provide richer, more actionable information. Reporting claim status and denials as soon as one-day post billing, ACS provides electronic access to payer proprietary remark codes and descriptions allowing you to understand why a claim is pending or rejected and to know it sooner. Using more comprehensive information to enable “workflow by exception” processes, ACS avoids the cost of unnecessary follow-up and frees your staff to pursue follow-up on the claims that would best benefit from further intervention.

When managed cost-effectively, and fueled with the right information, your claims follow-up strategy can help maximize your reimbursement and improve your revenue results. For follow-up made easy, learn more about our Advanced Claim Status (ACS) solution.

 

How to Improve Payments as HDHPs Increase Patient Responsibility

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Patient responsibility has always been a liability for providers. Unlike automated claims processing that submits electronic 837s to an established group of payers, the ability to collect on patient responsibility requires individual patient billing and often involves manual processing and time-intensive follow-up.

While the upfront dollar value of patient responsibility continues to increase across all plan types (HMO, PPO, POS, and HDHP) – now averaging $1,478 – the escalating adoption rate of high deductible health plans (HDHPs) means that a growing segment of the patient population is now responsible for greater payment amounts before insurance coverage begins. According to the Kaiser Family Foundation 2016 Employer Health Benefits Survey, 29% of covered workers are enrolled in an HDHP – up from 20% in 2014 – and the average HDHP deductible is $2,199.

As the financial liability shifts, the best way to reduce your exposure to uncompensated care is to expedite the collection of your patients’ responsibility—co-pay, co-insurance, and deductible.

Successfully collecting payment directly from the consumer rather than a payer may require a shift on the part of the provider: consider introducing a B2C payment processing model. Targeting patient payment processing solutions, both pre- and post-billing, this new B2C model should be patient-friendly and provide convenient and efficient automation with self-help payment options. The goal is to make it easy for patients to pay so you can collect patient payment as soon as possible.

Here are four steps you may want to consider.

1. Assist patients in making informed decisions.

Start by confirming your patient’s eligibility for the services to be rendered. While verifying your patient’s insurance and coverage, identify if there are any pre-claim requirements such as prior authorization and medical necessity documentation. Then calculate upfront your patient’s out-of-pocket cost, informing your patient of his/her responsibility. To learn more, visit A Smart Start to Your Revenue Cycle.

2. Collect patient payment information.

Think B2C. In addition to obtaining correct patient demographic information, consider gathering credit card information. Remember, HDHPs shoulder patients with a greater upfront cost burden. To get paid, providers need to be able to collect payment directly from the patient.

3. Make it easy for patients to pay.

Begin by communicating to patients easy-to-understand charges. Then offer convenient, accurate, secure B2C payment processing options—in today’s world, consumers expect online. In addition, consider offering payment plan options for select services. Smaller, easy-to-pay installments can help patients meet their responsibility. To learn more, visit Patient Responsibility Made Easy.

4. Coach your patient-facing staff.

Your patient-facing staff excels at helping patients with their healthcare needs. Now, coach your staff on how to help patients manage their payment responsibility. With assistance from your staff, your patients will come to understand their HDHPs and will learn to anticipate and know their responsibility in paying for healthcare services.

Most providers are already collecting a patient’s co-pay and co-insurance at time of service. With HDHPs, this model needs to be expanded to address a patient’s total out-of-pocket cost as it relates to the patient’s unpaid deductible. Finding ways to expedite your patient payments can help optimize your revenue cycle and accelerate your revenue cash flow.