Advanced Claim Status

Is your office spending too much time individually checking claim status? Did you know there is a much higher cost associated with manual claim status inquiries and that you don’t receive ‘actionable’ information from manually checking claim status?  

Advanced Claim Status (ACS) automates costly, manual and unnecessary follow-up tasks related to the status of claims as they move through the adjudication process. Integrating a richer and more complete claim status response into workflows saves staff time and effort and enables further automation. 

COVID-19: Insurers Exempt from Covering Workplace Testing

Must Cover “Medically Appropriate” Tests Only

The rapid rollout in March of the federal FFCRA (Families First Coronavirus Response Act) and CARES (Coronavirus Aid, Relief and Economic Security Act) Acts – and specifically section 6001 of the FFCRA, which defines requirements for insurers – has left providers, labs and insurers uncertain, at times, of their respective responsibilities for COVID-19 testing.

Avoid 3 of the Top RCM Pitfalls with Automation

Using different systems for RCM may be holding back productivity and hitting your bottom line.

The 2019 CAQH Index reported that the healthcare industry is spending approximately $350 billion annually for administration due to its complexity, and that about one-third of that amount could be saved by automating administrative transactions. For many, the mind-boggling $13.3 billion in available cost savings cited in the study begs this question: If healthcare revenue cycle management (RCM) technology has been evolving for over two decades, and the point of most technology is to help processes run more efficiently, what is causing administration costs to be sky-high with such an enormous opportunity for savings?

Don’t Be Tricked by Patient Access Management Vaporware

The foundation of the revenue cycle management process is patient access. Having a solution in place on the front-end can substantially minimize denials and rework on the back-end of the RCM process.

In addition to confirming demographics, insurance coverage and medical necessity, communicating the patient’s out-of-pocket responsibility before or at the time of service significantly increases the likelihood of receiving full patient payment.This shouldn’t be surprising. How many services do you receive that you have no idea what you are going to be charged? The healthcare industry has always seemed to operate amongst their own set of rules. But two major disruptors in the healthcare industry are going to start requiring more cost transparency and more of a partnership between the patient and physician:

1.  The transition to value-based care.
2.  Consumerism and the continued growth of high-deductible health plans.

As patients are becoming responsible for more and more of their healthcare costs – 30% of uninsured patients or patients who have out-of-pocket costs after insurance generate more than 80% of the hospitals’ self-pay revenue – we are seeing a decline in provider reimbursements for several reasons. The obvious reason is they simply cannot afford to pay their bill, which we will address later. Another less obvious reason is that they simply don’t understand why they are receiving a bill for services when they have insurance. Picture this:

Krystin goes into the hospital for a routine, scheduled colonoscopy. She pays her copay at the time of service and knows she has to pay $1,000 of her remaining deductible, which she also pays at the time of service. However, she is also responsible for coinsurance of 20% after her deductible is met, which is a new component of her health insurance plan that she doesn’t understand. The hospital doesn’t explain or inform her about her coinsurance amount. After the procedure, the provider bills the payer, and receives the explanation of benefits (EOB) stating that Krystin is responsible for $200, the coinsurance amount. The payer then sends Krystin a bill for the coinsurance, approximately 60 days after the service. Krystin receives the bill, but throws it away because it doesn’t clearly explain her balance and she knows she has health insurance, so it must be a mistake. She receives another bill, now 90 days after the service, and again, throws it away thinking it’s a mistake. When she receives a bill from a collection agency, she is confused and now very angry. She calls the provider and is informed about her coinsurance. She is furious that the hospital didn’t inform her about this amount before her service and vows to find a new provider for future services.

Dissatisfied patients also affect your front office staff who have to deal with the angry patients. This often leads to higher turnover rates, as staff will look for a better work environment.  That is why patient engagement should be a critical area of focus for your practice. The goals of successful patient engagement should focus on reducing or eliminating:

• Phone calls from angry or confused patients

• Patient statements because they can pay their bill online

• Collections because they have paid their bill or set up a payment plan

• Bad debt for your practice

Of course, that is the ideal state. Most providers have a lot of work to do to get there. But, it is possible. Providing an accurate out-of-pocket estimation is one of the pillars. This is also one of the main functions of patient access software that is commonly vaporware (i.e., software that has been advertised but is not yet available to buy, either because it is only a concept or because it is still being written or designed.) Vendors that are beholden to stockholders, scheduled releases, or big product launches at user group conferences can fall victim to overpromising and under delivering.

Going back to Krystin’s scenario, coinsurance is a piece of the puzzle that is often not included in an out-of-pocket estimation tool. That’s because the tool has to be diligent about maintaining the numerous payer fee schedules, which are continuously changing. Providing an accurate out-of-pocket estimate relies on a solid foundation of eligibility confirmation. A strong eligibility tool will be able to provide – in real time – a patient’s insurance coverage, including copays, coinsurance and deductible information.

Another important component of a patient access tool is determining the likelihood of the patient paying their bill. Checking credit scores and payment history can give you a sense for whether the patient will pay their bill. If it looks like they can’t or won’t, you have options to maximize your reimbursement before you provide the service – by asking for a partial payment or setting up a payment plan, for example.

Through our work with clients and discussions with potential clients, we’ve encountered a lot of skepticism around patient access – particularly the out-of-pocket estimation component. And, that’s where Quadax is different. We are in direct discussions with our clients every day, and our product development is driven by our clients’ needs.

When you’re looking at patient access solutions, don’t be tricked by vaporware. The right solution will be a real treat in maximizing your cash flow.

Ken MagnessKen Magness is a focused healthcare professional with more than a decade of experience in helping clients understand the true value of automation in the revenue cycle management process. As the Strategic Initiatives Leader at Quadax, Ken and his team are passionate about connecting with healthcare providers to help them create and leverage the appropriate technology solutions to optimize the revenue cycle process and improve the experience of their patients and staff.

Are You Collecting What You Are Owed? Five Tips to Help Plug Revenue Leaks

With so much of healthcare reimbursement administered by contracts, expected net patient service revenue is often a function of the payment terms and conditions found in payer-provider contracts. In order to identify underpayments, wrongful denials and shortfalls, labs need an effective, automated contract management solution as part of their A/R processes.

Why Contract Management?

Regardless of laboratory type or size, every lab can benefit from automating the validation of every single claim against the contracted amount. A proper contract management solution helps to increase a laboratory’s revenue by identifying every dollar that should have been paid per provider contracts, supplying data for contract negotiations, powering accurate revenue forecasting, and decreasing manual work hours dealing with contracts; all while automating underpayments and denials to help achieve 100% collectability.

5 Tips to Help Plug Revenue Leaks

    1. Utilize contract modeling to build all net patient service revenue contracts, provider-to-client invoice-based contracts, all payment terms and conditions, for multiple years, including:

• Medicare/Medicaid schedules
• Government, third-party payer and client billing fee schedules
• Fee schedules for non-contracted payers
• Percent of charges
• Percent of Medicare
• Carve outs
• Outliers

    1. Create and maintain an actionable workflow to help pursue priority claims during pre-billing based on expected revenue versus total charge. Be sure to define payment variance rules and apply post adjudication to determine next steps.
    2. Validate charges to prevent charge master errors before a claim is submitted by configuring non-contracted payer rules to validate acceptance of patient co-insurance.
    3. Take advantage of cash flow analytics and variance reporting to calculate cash flow by payer, age of claim, and where the claim is in the revenue cycle. This analysis and reporting will help identify opportunities for maximum cash flow improvements in the revenue cycle. Variance reporting specifically will provide an immediate indicator of adjudication outside contracted rates.
    4. Simplify the collection and revenue recovery process by identifying underpayments to trigger automated appeal process.

Plug your revenue leaks by identifying and collecting on underpayments and wrongful denials by being armed with the correct contractual data to appeal and overturn them. Contact us today to learn how Quadax can help you collect what your lab is owed!

 

The Power of Physicians

How will the healthcare system benefit from physicians unleashing their true power?

From hospital acquisitions to primary care shortages to the impact of telemedicine and value-based care, the role of the physician is changing. They now have an opportunity to take center stage in the new world of healthcare.

Key Takeaways from this presentation:

  • How policy changes impact independent physicians
  • Why physicians should embrace leadership roles
  • How the primary care physician role needs to be enhanced
  • The importance of data analytics to understanding the patient base

Download webinar

Tom Campanella PicturePresenter: Thomas Campanella, Baldwin Wallace University

Mr. Campanella is the Director of the Health Care MBA program and a professor of health economics for Baldwin Wallace University in Cleveland, Ohio. He also writes a healthcare blog on LinkedIn, follow him here.

Seven Keys to Success to Improve Out-of-Network Collections

Reimbursement in out-of-network care has grown to $60B and continues to grow due to the proliferation of narrow networks. Many providers don’t play in the out-of-network space or write-off a big chunk of revenue to close out an aging A/R. So what does an organization need to do in order to maximize reimbursement in this arena?

According to Richa Singh of Collection Rx, 5-10% of healthcare revenue is lost due to lack of time and technology associated with the work involved to follow up on the cost of collections resulting from unprocessed claims, missing documents, and denials. In many instances, providers overlook claims that are not properly processed and, as such, miss out on revenue. More importantly, almost 40% of that revenue loss is in individual out-of-network claims, mostly due to inexperience with these types of claims as a result of no data with the payers and no time or staff to commit to understanding their rules let alone track down the revenue.

Many providers don’t play in the out-of-network space or write-off a big chunk of revenue to close out an aging A/R. Yet with so many stringent rules for in-network, the biggest revenue growth opportunity exists in out-of-network care! So what does an organization need to do in order to maximize reimbursement in this arena?

1. Understand Payer Tactics

Payers, unfortunately, have cost containment practices on what they consider unnecessary tests or treatments. When these services or payment are not contracted or clearly understood, providers miss out. You need to:

• Know a payer’s out-of-network payment trends and policies
• Have access to the data to prove a payer’s inadequate reimbursement
• Be persistent
• Dedicate the right resources with your efforts

Getting ahead of these roadblocks with technology to support your efforts of clean claims, maintain proper documentation, provide medical necessity, show submission of claims, and decipher EOBs will help increase out-of-network reimbursement.

2. Invest in Technology

Data and automated workflow rules will help improve your overall reimbursement rates and ensure you get paid for your services. Areas of suggestion include:

Workflow – Automate manual processes as much as possible
Data – Analyze data and comparable claims to understand payer trends
Coding – Supports workflow optimization to lower collection costs
Analytics – Deep dive into your metrics for strategic planning

3. Maintain In-depth Reconciliation Process Through Collections

Avoid missed revenue with automated workflow and checks and balances throughout the collection process.

4. Streamline Your Workflow

Identify weak links in the front-end of your A/R to avoid issues on the back-end, improving staff time management and reducing the cost to collect.

5. Gain Expertise in Out-of-Network Benefits/Payments

Drive business decisions by having access to actionable data that will allow analysis, such as root cause identification on underpayments and denials, and help identify trends, projections, and revenue impact on a weekly, monthly and even ad hoc basis to help improve financial performance.

6. Gain Out-of-Network Expertise

With a growing market of unrestricted contracts in out-of-network, there is an untapped opportunity to increase reimbursement rates and impact your bottom line. You need to know the trends and tendencies of out-of-network payments, have comparable data to counter tactics, and understand those tactics.

7. Outsource Payer Collection Efforts

Ensure your partner is provider-centric in that it is providing access to your collection data, helping you with reporting and understanding metrics of importance, and offering frequent success and troubleshooting reviews.

8. Enhance Patient Experience

Pricing transparency has been shown to improve collection efforts for self-pay patients. When a patient is aware of their financial expectations sooner, labs and the ordering physicians can avoid the run-around that often results from “surprise bills.”

Quadax specializes in helping healthcare providers maximize reimbursement – both in- and out- of-network – through billing and software solutions geared to solve the challenges associated with navigating the payer landscape to help expedite claims and payment processing. Want to learn more? Let’s talk!

Content adapted from Strategies for Success in Out-of-Network and Payer Reimbursement, May 2019.
https://www.beckershospitalreview.com

Realign Claim Follow-Up Value For Today’s Revenue Cycle

Take a deeper look at effective claim follow-up and how it can inform upstream denial avoidance measures.

How can you realign your follow-up process to deliver the value you really need for today’s revenue cycle?

Effective claim follow-up enables a healthcare facility to proactively identify and begin working claim denials or requests for additional documentation. The most commonly used methods of claim status checking are fully manual, partially electronic, and ANSI.

In this guide we will cover each of these methods in terms of effectiveness by asking the following questions:

√  Information quality: is it actionable?

√  Response speed: is it timely?

√  Effort required: is it cost-effective?