This guide aims to explain the ins and outs of the Medicare claims process and outlines the necessary tools to make your life easier and help maximize your reimbursement.
Category: Resource Center
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 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.
Is Your Lab Collecting What It’s Owed?
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
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- 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
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- 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.
- 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.
- 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.
- 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
Presenter: 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 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?
How to Improve Patient Satisfaction and Your Bottom Line
Patient satisfaction is an important goal for providers for reasons going way beyond a desire to be kind humans. It’s the first part of the Institute for Healthcare Improvement Triple Aim.[i] Better patient satisfaction has been associated with better medical outcomes and with reduced readmissions.[ii] Patient satisfaction scores influence reimbursement, both for the Inpatient Prospective Payment System (IPPS) and value-based care. And, in an era of competition for patients from non-traditional healthcare outlets, ensuring patient satisfaction is an important way to protect patient relationships and future revenue opportunities.
Ways to achieve better patient interaction are not closely-held secrets. Lists of helpful tips may be found in abundance in collections of 5 or 10 or even 30 top ways to improve patient satisfaction. Boiled down to the most common theme, though, it’s all about Communication, Communication, Communication.
The characteristics of good communication– listening patiently and respectfully, making eye contact, answering questions fully, expressing empathy –belong in both the clinical and in the financial environment.
Communicating Patient Financial Responsibility
The Healthcare Financial Management Association (HFMA) published a comprehensive guide to patient financial communications in 2016 which remains a valuable resource on the topic. The guide was developed in partnership with experts including representatives of patients, hospitals, and physicians, advised by national policymakers including Sen. Tom Daschle, Sen. Bill Frist, former Secretary of Health and Human Services Donna Shalala, and others. Its goal is to bring “consistency, clarity, and transparency” to patient financial communications with best practices for Emergency Department (ED), time of service (outside the ED), and advance of service settings.
One best practice identified for all settings is, “Providers should have technology that gives financial representatives up-to-date information about patient balances and financial obligations.”
Patients today are frequently, and understandably, anxious about the debt they may incur for diagnosis and treatment. Twenty-five percent of Americans, according to Gallup, name cost as the most urgent health problem facing the U.S. Forty-five percent of Americans fear a major health event will leave them bankrupt.
Clear, credible, compassionate communication, then, about a patient’s financial obligation is essential to caring for patients in a way that will foster satisfaction and result in better outcomes.
Fortunately, the technology to give patient access or financial representatives up-to-date estimates of a patient’s out-of-pocket responsibility is available and easy to use.
In the Quadax Patient Access Management suite, the Out-of-Pocket Estimation tool is a contracts-based estimation engine able to produce an individual professional or technical estimate or a combined estimate. The engine analyzes the provider’s negotiated contractual stipulations, chargemaster, historical procedural information, and patient-specific, year-to-date benefit data to arrive at the best estimate of a patient’s financial responsibility possible prior to the current procedure. Auto-add technology includes related procedure codes—additional procedures found to generally be done in conjunction with the primary procedure—for a more realistic estimate to eliminate surprises down the line.
Patient Access representatives using the Quadax Out-of-Pocket Estimation tool are guided through the process of generating the estimate and talking with the patient about the document. Through this open communication, a patient is better equipped to make care decisions and financial plans, and is more likely to express satisfaction about the financial communication experience with their healthcare provider.
Are you ready to learn more about the role an easy-to-use Out-of-Pocket Estimation tool can play in your mission to provide care to your patient population? Click here to request a no-obligation consultation.
Fostering high patient satisfaction is one way of thriving in an environment of increased competition for patient-consumers. A recent Definitive Healthcare survey of important trends identified consumerism as the second most important topic causing apprehension for healthcare providers. If the rise of consumerism in healthcare today has you concerned about the implications for your practice and for your patients, request our latest White Paper, Healthcare Consumerism & Your Revenue Cycle: Flip the narrative and build loyalty through patient-centric tools and processes. Request your complimentary copy here.
[i] http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx
[ii] Jacob Imber, MD, “Lower rates of patient satisfaction may predict readmission,” The Hospitalist, May 23, 2019, https://www.the-hospitalist.org/hospitalist/article/201061/mixed-topics
Healthcare Consumerism & Your Revenue Cycle
Take a deeper dive into understanding consumer trends and how they affect the management of your whole revenue cycle.
Patient Bad Debt Impacting Your Bottom Line?
Solve issues early. Collect payment faster.
Discover the benefits of engaging patients early, getting ahead of revenue cycle problems— stopping claims from turning into denials or resubmissions— by collecting correct patient information at the point of care. Learn new strategies to reduce time from DOS to claim generation and increase visibility into revenue flow through the use of Analytics.
This presentation explores the benefits of providing rich, consumer data assets and insights into consumer financial behaviors to increase registration process accuracy, create more transparent and positive patient experience, empower staff members to make consistent intelligent decisions, and offer providers a way to maximize staff efficiency.
Key Learning Objectives
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- Understand the impact of market trends.
- Discover practical solutions integrated at the point-of-decision to manage the challenges associated with incomplete or inaccurate patient information, increased patient financial responsibility, and unique payer requirements.
- Review the value of integrated API solutions from the front-end to the back-end of the revenue cycle.
Presenter:
Missy Tubbs
Senior Product Manager
Quadax, Inc.
Patient Access Antidote: How Labs Can Retain More Revenue
Patients’ financial liability in paying for healthcare services is almost unrecognizable from that prior to the early 2000s; yet many organizations, including clinical laboratories, have struggled to modernize their collection practices in turn. As a result of this mismatch, labs risk not just losing out on uncollected revenue, but also wasting time and resources on futile or minimally effective back-end collection efforts.
Reversing the problem is possible, however, by implementing the right best practices and revenue cycle management technologies. In particular, maximizing patient access early in the revenue cycle can help patients manage their financial responsibility and preempt many unnecessary denials, payment delays, and uncollected balances.
In this Dark Daily white paper – Patient Access Antidote: Retaining More Revenue with Front-End Solutions – take a deeper dive into the consumer trends having an impact on revenue cycle management, best practices in patient access management, and the expert-recommended tools and solutions that clinical laboratories can employ to respond.
We are also presenting on Patient Access topics at the 24th Annual Executive War College. If you are attending, don’t miss these opportunities to learn new strategies to help your lab sustain financial stability and growth. {Quadax is proud to be a Benefactor Sponsor of this annual conference.}
| Tuesday, April 30 | 8:30 a.m. | Brean Bark Director, Product Development |
| Missy Tubbs Senior Product Manager |
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| Patient Responsibility & Payer Pre Billing Requirement Impacting Your Bottom Line? Engage Physicians and Patients with Patient Access Solutions & Analytics To Improve Revenue. |
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| Wednesday, May 1 | 7:30 a.m. | Walt Williams Director of Revenue Optimization and Strategy |
| Are Your Patients Now Your Payers? New Tools Empowering Your Lab to Collect More Money, Faster, and at Less Cost.
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At Quadax we take on your billing needs so you can do more to improve the delivery of value-based care and transform patient outcomes. Explore our revenue cycle optimization solutions to expedite payment, maximize reimbursement, and enhance visibility into your business. Get in touch with our RCO team and discover how we can help you create areas of opportunity to achieve the best possible revenue outcome.