Helping providers prepare for what some have called a coming reimbursement war, the tech firm SAI Global Compliance has unveiled an application called the "Claims Denial Manager," designed to limit losses from pre-payment claims denials.
Georgia-based SAI Global developed the claims denial app to work with its audit manager software suite, John Brooke, the company's general manager of healthcare, said. It's a sort of "virtual traffic cop," he said, giving providers "the complete visibility needed to monitor and proactively manage their financial exposure stemming from pre-payment and post-payment claims audits and denied claims."
SAI Global estimates that its client hospitals have successfully appealed some $40 million in claims denials using the audit manager software.
The company's new claims denial app evolved from customer requests, Brooke said, to help in the area of pre-payment claims denials. Especially with Medicare and the Recovery Audit Contractor program, Brooke said, hospitals have tended to write off denied claims, and "these same customers have seen increasing threats to their revenues stemming from pre-payment denials."
The claims denial app works with both artificial and human intelligence, Brooke said. It continuously mines the claims data and finds patterns based on claim adjustment reason codes and payer and payment information, and then processes individual claims and remittance advices.
The app then helps allocate the workload of claims denial review and appeal and creates an audit and document trail of the claims review and resubmission decisions.
With graphical representations and reports on all of those processes, Brooke said, provider "managers and executives always have clear visibility into financial exposure and trends along with actionable intelligence into the root causes of denials to target areas for improvement such as coders, physicians, service lines and payers."
Amid broader changes to payer-provider relationships and healthcare industry-wide pressure to control costs, reimbursements are sure to one contentious area, with physicians arguing for fair payments and insurers trying to limit unnecessary and excessive procedures.
As the healthcare industry transitions away from fee-for-service, new reimbursement models and delivery systems may be tried and tested, with both successful and failure. Some in the insurance industry have called for a push towards value-based reimbursement models that incentivize patient health and wellness rather than factory-like care.
At a recent America's Health Insurance Plans conference on the topic of value-based reimbursement, McKesson's assistant vice president of product marketing Nicole Nye outlined four areas to watch in transitioning to value-based systems: reimbursement model design, provider network analysis, member understanding of new configurations and more efficient and code-friendly payer-provider contracts.