Doing More with Less, The Value of Automated Claims Status Reporting

I just took my dog to the vet. A thorough exam by a qualified clinician, a few medications (filled at their office) and we were out the door in an hour. There was a bit of sticker shock, but with no insurance, I had to pay it in full. To borrow health care parlance, all incentives were aligned: the dog feels better, I knew what I had to pay for and the veterinary practice got paid immediately.

If you think back to your last trip to the hospital or large medical practice, I’m guessing it was nothing like my recent visit to the vet. If you’re a hospital CEO or CFO, you wish cash and insurance-based reimbursement flow was that smooth. EHRs, ICD-10, MU, and now MACRA – the alphabet soup most hospitals have to navigate is excruciating – and that’s before focusing on revenue cycle management. Instead of revenue flow, it’s more like revenue drag. Countless hours are wasted in the claims follow-up process, when business offices manually call payers to update claims and denials status. Or, due to resource constraints, claims are not followed up on at all, leading to unnecessary write-offs and missed timely filing.

The delay in getting paid isn’t just bad for providers—it’s bad for the entire health care system. As hospitals are increasingly being tasked to do more with less, such chronic delays threaten the financial sustainability of those on the front line of delivering care. According to Becker’s Hospital CFO, 12 hospitals closed in 2016, up from 9 in 2015, due in part to an inability to capture revenue at timely intervals.

With these statistics ringing in their ears, it’s no wonder hospital executives are getting a handle on denial management by automating as many aspects of claims processing as possible. Leveraging proprietary web-based technology, hospitals can automate the portions of the insurance billing and follow-up process.

Claims status automation works on four fronts:

  • Accelerate Claim Resolution – additional content gleaned directly from payer websites guides users to take steps to quickly resolve pending or denied claims. Claims that don’t require any action remain untouched, eliminating the need for follow-up calls and scouring payer portals and remittances.
  • Richer Data – an automated web-bot devoted to claim status helps to determine proprietary reason codes from a payer that may be missed by more generic 276/277 EDI transaction data in order to provide a richer, more actionable data set, delivered in an easy to read format.
  • Reporting Insights – a series of reporting dashboards continuously improve the process to help minimize ineffective workload and resolve the portfolio more quickly based on more effective follow-up. The dashboards make it easier to track activity and compare financial performance results, and use consistent reporting standards, which in turn improve visibility to spot revenue recognition and timing.
  • Auto-route problem claims – workflow triggers auto route problem claims to appropriate staff for remediation. Once approval status and scheduled payment date information is auto-populated into the system, the hospital or provider organization is on its way to truly “touchless” claims.

Automating claims statusing takes the manual and tedious and helps focus precious resources on claims that matter. Still, it’s not just the solution to transform hospital business offices. It’s a sophisticated tool forward-thinking hospitals should have in their business office tool kit, to maximize productivity and achieve the revenue cycle results necessary to continue to offer excellent healthcare.

By Lori M. Jones, Chief Revenue Officer, Connance