Perhaps the biggest problem with antiquated claims processing methods is the wondering:
- Did the claim go through?
- Was it complete?
- Is there a hang-up somewhere?
- Where exactly is the claim?
- Will it be paid or will be it be rejected?
- When will the payment be made?
All of these questions arise when the financial operations staff doesn't have a window into revenue cycle machinations. Consequently, losing a claim in the pipeline results in lower productivity from time wasted chasing down information, rising days outstanding levels and higher costs.
Physician practices are especially vulnerable to claims processing snags, says Bill Gilbert, vice president of marketing for Warren, N.J.-based AdvantEdge Healthcare Solutions.
"The most important revenue cycle issue for most physician practices is preventing denials," he said. "It is hard work because denials represent the 10 to 20 percent of the claims that cause 90 percent of missed revenue opportunity. Some practices let denials accumulate, which obviously leads to missed collections and longer accounts receivable intervals. Other practices assign staff to work denials and get them turned around more quickly. However, the best approach is to analyze denials, determine their root cause, and implement action plans to eliminate the cause."
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Most systems used for physician billing get the basic job done, Gilbert said, but in an era in which vendors are rapidly expanding system capabilities, "it is common to find revenue cycle workflows that are inefficient and, in some cases, ineffective."
Ralph Bernstein, senior vice president of Minneapolis-based U.S. Bank Healthcare Payment Solutions, sees the collection of patient receivables as the most important revenue cycle issue for providers.
"For years, providers have spent too much time and money chasing patient responsibility dollars that have walked out the doors of their practices, hospitals and clinics," he said "However, until relatively recently the amount of patient receivables was not great enough to merit much concern on the part of those providers. Things have changed - significant year-over-year increases in health insurance premiums have sent more consumers in search of lower-premium, higher-deductible, higher out-of-pocket health insurance plans. As a result, providers must now pay attention to an unprecedented level of patient receivables."
The need to collect patient receivables will only increase in the next few years, Bernstein says, as millions of consumers receive health coverage for the first time due to healthcare reform.
"Without some critical changes to provider workflow and revenue cycle management practices, providers will, in coming years, spend even more time and money chasing patient receivables and dealing with increased levels of uncollectible patient responsibility dollars," he said.
Simplifying the process
Mission Surgery Center in Orange County, Calif., previously had a convoluted claims processing system that caused major headaches for business office manager Ramona Dwight.
"We relied on a clearinghouse to manage the claims process - the service was extremely slow, taking upwards of days to gather information necessary to begin processing a single request," she said. "It was so time consuming and labor intensive."
With claims often left unmonitored, the center spent "countless hours following up" with the clearinghouse. In many instances it was simply quicker for the center's staff to manage claims themselves, particularly when calls to the clearinghouse were unanswered or issues went unresolved, she said.
After adopting the automated system from Louisville, Ky.-based ZirMed 18 months ago, the surgery center's claims processing instantly improved, Dwight said.
"Before when I sent a batch of claims, it would take five to seven days before it would be accepted or rejected - and sometimes it didn't do either," she said. "When that happened, I had to call the clearinghouse to find out the situation. With ZirMed I do the batch and in 10 minutes I can see what was accepted or rejected."
Since adopting the ZirMed system, DSO days have been cut nearly in half and the center's average hovers around an optimal 45 days, Dwight said.
Jim Lacy, ZirMed's CFO and corporate secretary, says its product suite can be adapted by any provider organization and will give users "a holistic view" of its revenue cycle operations.
"It's about automating the workflow," he said. "Our system translates across the spectrum for healthcare because everyone's revenue cycle process is basically the same."
Making a connection
Having a transparent view of claims internally helps the billing staff better manage their workflow, but that is only half of the equation. Providers also need context once claims are sent to the payer.
Stamford, Conn.-based IVANS specializes in Medicare claims and "provides the last mile" of connectivity for providers and carriers, said President Clare DeNicola.
By downloading software hosted in the cloud, IVANS offers providers a "connection out the back side" with payers, DeNicola said.
The IVANS system helps speed cash flow and creates efficiencies for checking and validating eligibility while shaving down DSOs and helping business offices eliminate positions related to paper processing, she said.
DeNicola insists that her company "is not a middle man" and that claims "go straight to the payer."
Similarly, Carmel, Ind.-based Zotec touts is ability to give providers "a direct handshake with carriers" while bypassing clearinghouses with its outsourcing services, said partner Mark Isenberg.
"Providers are pretty sheltered from the back office function," he said. "Too often they don't know if the carrier has received a claim or specific details about a claim. We help them get claims filed on a daily basis and get them paid as quickly as possible."
On the payer side, fraud is a major issue as the government estimates bogus claims drain billions from the healthcare system. Fraud is reportedly so pervasive that the federal government simply cannot regulate it on its own.
So Independence Blue Cross in Philadelphia has taken matters into its own hands and recently implemented a system that empowers its enforcement team. IBC worked with Fairfax, Va.-based General Dynamics Information Technology to implement the company's STARS and STARSSentinel programs to analyze and investigate fraud and abuse cases.
The software enabled IBC to more productively investigate suspicious claims, resulting in the recovery of nearly $71 million in overpayments, said Ed Litchko, IBC senior director of corporate and financial investigations.
Litchko heads up an investigative team that probes into fraud, waste and abuse by examining claims from hospitals, physicians, durable medical equipment providers and pharmacies. By using the STARS data mining IT application, investigators can identify the most aberrant billing patterns and take a closer look where warranted.
While the system has been a tremendous help in flagging suspicious claims, it does not take an overzealous approach, Litchko said.
"We realize that mistakes are made and that maybe a provider didn't intentionally step over the fraud line," he said. "The first thing that happens is that the provider is notified about incorrectly using a code or improper combination of codes. If auditors receive questionable responses to their inquiry, then there might be something worth investigating further."