Healthcare Loses Billions Due to Over-Reliance on Manual Tasks

Healthcare Loses Billions Due to Over-Reliance on Manual Tasks

We already know the trend toward automation in healthcare continues to grow each year. As technology continuously improves and the financial bar to entry lowers, the opportunities for healthcare providers and health plans to enhance operational processes grow as well. But even with the radical progress and the easier-to-use-than-ever healthcare operations software, many organizations fail to implement the solutions. It may be a lack of organizational enthusiasm or a simple need for more skilled internal technological expertise.

And while this is likely common knowledge at your organization, the amount of money wasted each year – driven by the absence of process automation – may not. Billions of dollars that could otherwise be spent on improving patient care and satisfaction, on building and rolling out new service lines, and generally improving healthcare operations are wasted every year. Billions.

The most recent CAQH Index reports $372 billion is spent yearly on administrative tasks throughout the US healthcare system. Of that amount, $39 billion of those administrative transactions are specifically tracked by the CAQH Index. “Of the $39 billion, the industry can save $16.3 billion, or 42 percent of existing annual spend, by transitioning to fully electronic transactions,” according to CAQH.

$16 billion in savings.

The current opportunity for savings driven by automated, electronic transactions within the healthcare industry is tremendous. That’s not to say the healthcare industry is doing nothing. CAQH found that healthcare organizations already save $122 billion annually thanks to process automation.

Even with the apparent success of automation, however, CAQH found the utilization, adoption, and growth of fully-automated processes year-over-year was stagnant or modest at best:

      • Eligibility and benefit verification remained steady at 84%
      • Prior authorizations increased to 21% from 13%
      • Claim status inquiry grew slightly to 72% from 70%
      • Claim payment automation increased marginally to 71% to 70%

With the small and slow shift to the use of automated transaction processes in the healthcare industry, there’s a decided advantage–in time and money–to not automating many, if not all, backend operations. Doing so allows staff to focus on strategic initiatives, like building out new programs or service lines, rather than plodding through everyday tasks better tackled through repeatable processes supported by technology.

“The industry continues to make progress towards a more automated administrative workflow as transaction volume increases, new business needs and technology emerge, and health insurance benefit and payment models evolve,” CAQH explains in the report. Nevertheless, as mentioned earlier, the “progress” remains slow, like a river choked with debris.

Ironically, even as automated solutions become more abundant and easier to use, CAQH reports healthcare providers to perform more manual tasks today than in the past. With today’s technology-rich environment, there’s little reason for healthcare providers to input any type of care-related documentation by hand. That time can and should be better spent improving the healthcare experience for patients and their families.

It’s far past time to clear the detritus from the river. With the advantage of today’s technology, it’s easier to make the change when each of us plays a part in the cleanup.

Contact a TriZetto Provider Solutions representative today to learn more about automation-enabled technologies that can help drive efficiencies and increase revenue.


ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.

[ Contribution from the marketing team at TriZetto ]

Medicare Revalidation is Critical to Maintaining Eligibility

Medicare Revalidation is Critical to Maintaining Eligibility

Medicare is the largest payer for most practitioners, so it’s important that providers maintain current credentials. Medicare requires providers to revalidate every five years to verify credentials and ensure they meet Medicare qualifications. Providers must confirm or update information including the legal entity name, physical address, phone, fax, national provider identifiers, employer identification number, and board certifications and licenses if applicable.

While typically a straightforward process, if not completed correctly and on time, providers will be terminated from the program and required to reapply. Until a new application is processed and approved, which can take anywhere from 90-120 days, reimbursements will stop, disrupting the revenue cycle.

Occasionally, providers may receive off-cycle revalidation requests. These are typically triggered when anomalies are identified such as billing rates that are significantly higher than other providers in the same geography, billing for services not rendered, or billing patients for services that Medicare doesn’t allow.

To comply with Medicare revalidation requirements, providers need to know their revalidation schedule and make sure applications and supporting documentation are submitted through Medicare’s PECOS online application portal. Revalidation dates cannot be extended, so it’s important they’re submitted on time. Using a third party to navigate the nuances of Medicare revalidation and PECOS removes the burden from provider staff and ensures accurate and timely filing.

TriZetto Provider Solutions (TPS) offers an end-to-end credentialing service that includes continuous payer follow-up and insight into enrollment status. Our dedicated team takes provider data, verifies it for accuracy, and submits credentials for revalidation through PECOS. All Medicare-participating providers are subject to revalidation, and mistakes made before or during the process can result in loss of eligibility and other penalties.

Having nearly four decades of experience working with payers and providers, the TPS credentialing experts understand the importance of maintaining current credentials. Contact us to learn more about our Medicare revalidation services.


ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.

5 Medical Coding Challenges That Hurt Revenues

5 Medical Coding Challenges That Hurt Revenues

In the world of healthcare revenue cycle management, there are numerous scenarios that can put a stranglehold on your revenue if you’re not prepared. With the COVID-19 pandemic causing varying degrees of change in inpatient volumes and visits, and telemedicine coming further into play, physicians and their practices are having to quickly navigate the nuances of their financial well-being. A practice may be buttoned up from the time the patient walks in the door, but what happens after the visit will determine when the practice will get paid. This element of the revenue cycle starts with coding. Here are five medical coding challenges that will ruin your bottom line.

1. Coding to the Highest Specificity
Missing data on a claim relative to the patient’s diagnosis and procedure can easily cause a rise in denials once received by the payers, resulting in potentially thousands of dollars in write-offs. Medical coders are responsible for coding patients’ claims to the highest level of specificity, ensuring the appropriate CPT, ICD-10-CM, and HCPCS codes are applied based on the patient’s chart from the day’s services.

COVID-19 and telemedicine are frequently bringing on new codes and code sets, all with different variations and modifiers to make the matter even more complex. Medical coders spend a lot of time researching and learning new codes, but every year – and throughout the year – changes and updates are made. Payers don’t only want to know the diagnosis and the treatment; they want to know the cause as well. The Coronavirus Aid, Relief, and Economic Security Act passed in March of 2020 allows for an additional payment from Medicare of 20 percent for claim billed for inpatient COVID-19 patients, however, it was later indicated that a positive COVID-19 test must be stored in the patient’s medical records in order to be eligible for this payment. Being able to stay on top of codes specific to the patient’s diagnosis at treatment is more difficult than ever before.

2. Upcoding
While code specificity is important, so too is ensuring the claims do not contain codes for exaggerated procedures, or even procedures that were never performed, resulting in reimbursement for these false procedures. This seems logical enough, but upcoding can easily occur as a result of human error, misinterpretation of a physician’s notes, or lack of understanding of how to appropriately assign the thousands of ICD-10-CM codes in existence. To add to the pressure, the Office of the Inspector General issued a plan with objectives to prevent fraud and scams, and remedy misspending of COVID-19 response and recovery funds.

Much like under-coding or not providing enough data on the patient’s visit can create issues, upcoding can be a major contributor to financial loss for a practice. Questionable claims can be denied and sent back for corrections and appeals, but upcoding can have more serious ramifications outside of paper-pushing between coders and payers.

Whether it’s making sure the codes are in accordance with the care provided, understanding the code sets that apply for each procedure, or comprehension of the medical record, refraining from upcoding will help ensure a sturdy and compliant revenue stream.

3. Missing or Incorrect Information
There’s a common theme to coding challenges, and that’s having the sufficient information necessary. This information typically is pulled from a patient’s chart or record of a visit, which is often completed by the attending physician. However, even when a claim is submitted, providing required information relative to the procedure to the payer is critical as well. Situations such as failure to report time-based treatments (such as anesthesia, pain management, or hydration treatments) or reporting a code without proper documentation can result in denials.

Furthermore, information in a patient’s electronic health record may also contain inaccurate information. Keystrokes and other human errors can cause these situations to flare up, and it takes a diligent, thoughtful coder to read between the lines and ensure claims have the appropriate information.

4. Timeliness of Coding
The Medical Group Management Association (MGMA) suggested in their 2018 Setting Practice Standards report that a Primary Care Physician should maintain a claim submission rate of 3.11 days after the date of service, but it is becoming increasingly difficult for practices to sustain anything close to this rate. Constant changes to code sets, an increased focus on submitting claims with sufficient and compliant information, and the requirement to code claims to the highest level of specificity, can easily delay the submission by days or weeks.

Nevertheless, delays in coding and submitting claims can cause major lags in payment and substantial loss in revenue. Insurance payers have statutes of limitations that require claims to be submitted anywhere from 120 to just 60 days after the date of service. Simply put – the more time spent coding the claim, the later it will be submitted, thus increasing the odds that the claim will be denied. Expert coders are aware of this and do everything in their power to get coded claims out the door.

5. Staffing Shortages
However, finding experts well versed in coding claims quickly, accurately and in compliance with the False Claims Act is not always an easy task. As you can imagine, the increasing need for care within the senior population is causing a rise in claim volumes, and trying to find a team of coders who know the ins and outs of complex ICD-10-CM coding can easily cause a bottleneck in the revenue cycle. Health executives expressed their struggles to find talent back in 2015, and some forecasts expect a decline in commercial payments by 2024 to further hamper a C-suite’s ability to manage labor costs. The ramifications of incorrect coding are still a key topic of discussion to this day.

The time has come for practices to begin looking outside of their organization for coding support. How is your practice planning to tackle the coding conundrum? When choosing a partner for your medical coding needs, you need to pick an expert to help your practice stay on target. TriZetto Provider Solutions, a Cognizant Company, has available highly-trained, AAPC & AHIMA certified coders with the experience of getting the details right the first time and understand the importance of coding to the medical practice.

For more information about TriZetto Provider Solutions, a partner of EZClaim, visit their website, contact them, or give them a call at 800.969.3666.


ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.

[ Contribution of the TriZetto Provider Solutions Editorial Team ]

What Is Meant by Price Transparency?

What Is Meant by Price Transparency?

What is Price Transparency?

It’s a story we hear too often. A person visits a hospital for a medical issue—whether it be a trip to the emergency room for a broken arm or a pre-scheduled appointment for a headache that just won’t go away—and receives a myriad of services and tests. Then comes the dreaded bill in the mail a few weeks later. Although they may inquire about an estimate at the time of service or have an idea of their coverage, the exact financial responsibility is often a mystery until that bill arrives. While the changes vary greatly, one thing that is certain: many people have trouble with their out-of-pocket costs. So much so that a recent survey from The Commonwealth Fund found that 72 million Americans have some sort of trouble with medical debt.

So, on January 1, 2021, the price transparency rule was put into effect—from the Centers for Medicare and Medicaid Services (CMS)—requiring all hospitals within the United States hospitals to publish the prices of various medical procedures. In particular, standard charges for services and items must be published online, available for patients to access. Until now, these prices were hard to find. The timing of this change—the beginning of the calendar year—comes at a time when healthcare pricing is top of mind since many customers most likely renewed or changed insurance carriers and coverage on January 1, 2021. With this comes a focus on out-of-pocket costs, deductibles, and more.

What Brought About This Radical Change?

Part of this change can be attributed to the consumers themselves. With the increase in high deductible health plans and increased out-of-pocket costs, finances are top of mind. In addition to these factors, today’s consumers demand a better overall patient experience. With the prevalence of online shopping, patients expect the same seamless transaction at the hospital that they receive with companies like Amazon, Walmart, and Home Depot. Just as consumers read product reviews before placing an item in their online shopping cart, patients research services and access peer reviews of physicians before they go to the office. In short, they want to be knowledgeable about their healthcare and crave tailored services with exceptional customer service.

Many believe this change will be well received, with Forbes calling the ruling a gift to all Americans. From the consumer’s standpoint, it will now be easier to make educated decisions based on cost. This will then cut down on the “unknown”—hopefully eliminating those hefty surprise bills—and opens the door to comparison shopping. Advocates are hoping this newfound transparency will eventually lower costs, with the competition eventually driving down the prices.

How Can Healthcare Organizations Navigate This Change?

This will not only promote transparency but will also increase convenience. By enabling patients to access and pay their bills on their own schedule with easy-to-implement solutions, organizations are meeting them halfway, so to speak. With easy-to-understand statements, integrated credit card processing, and 24/7 payment portals, it is no longer a hassle to manage medical financials. For healthcare organizations, facilitating proactive management of a person’s cost of care accelerates revenue collections and patient satisfaction improves.

In the larger sense, executives recognize that patients are taking more stock in their personal care. In order to thrive, hospitals and health systems must work toward creating the optimal patient experience, beyond just price transparency. With this, providers should aim to be more engaged and C-suite executives should try to provide additional benefits to their patients.

What Will This Mean for the Future of the Industry?

Only time will tell what the price transparency will mean for the industry. However, it is safe to say that this concept has the possibility to shape healthcare policies and processes for years to come.

So, for more information on solutions that equip you to have informed conversations about eligibility and financial responsibility, contact one of EZClaim’s partners, TriZetto Provider Solutions, to talk with one of their representatives today.


ABOUT EZCLAIM:

EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.

Article contributed by TriZetto Provider Solutions Editorial Team ]

Managing Complexities of Behavioral Health Credentialing

Managing Complexities of Behavioral Health Credentialing

The COVID-19 pandemic has put a spotlight on the need for mental health resources as illness, job losses, and isolation continues to create unprecedented stress levels. According to recent surveys conducted by the Larry A. Green Center, more than half of clinicians reported declining health among patients due to closed facilities and delayed care, and more than one-third noted that patients with chronic conditions were in noticeably worse health as a result. Even more striking, over 85 percent reported a decline in inpatient mental health with 31 percent seeing a rise in addiction.

With mental health access at the forefront of our minds, there is no doubt a demand for qualified professionals that can handle these complex patient needs. While the sense of urgency for these services exists, especially as more and more healthcare consumers are resuming in-person appointments, unfortunately, there are processes in place that can create unnecessary roadblocks for practitioners.

Complying with the Council for Affordable Quality Healthcare’s (CAQH) behavioral health credentialing requirements are especially challenging. Unlike traditional medicine, treatments and therapies for conditions such as addiction are not as well understood by payers. This makes it more difficult to gain or maintain the credentials necessary to submit claims for therapy services.

Ninety percent of the time counselors and therapists apply for network status are denied! That’s a striking statistic, even for seasoned professionals, and everyone can agree that appealing denials and requesting payers review credentials in greater depth are a time consuming and expensive burden. On average, the time required for behavioral health credentialing of professionals is up to five times greater than for medical professionals because of nuances specific to the industry. The turnaround for completed enrollments is slower too, on average 180 days versus 120 days. In addition, some payers will only allow certain therapies for providers without advanced degrees. Because denials for behavioral health are common, therapists must understand which therapies a network will accept and focus on therapy-specific credentialing. In the current environment, practitioners should also ensure that Telehealth or virtual appointments will be covered for the safety of all.

 

So how can mental health providers stay ahead of enrollments and avoid credentialing-related denials? Outside assistance from experts like those at TriZetto Provider Solutions offers an end-to-end credentialing service that ensures continuous payer follow up and insight into enrollment status. Our credentialing professionals are devoted to helping providers gain and maintain their credentials. We understand the nuances associated with behavioral health credentialing and have direct relationships with all major payers. TPS allows you to do what you do best – manage patient care – by alleviating the burden of credentialing and making sure you never miss quarterly re-attestation deadlines.

If your mental health services are being denied, we are here to help. Learn how solutions from TriZetto Provider Solutions can help your practice simplify credentialing.

 

TriZetto Provider Solutions is a partner of EZClaim and can assist you with all your coding needs. For more details about EZClaim’s medical billing software, visit their website, e-mail their support team, or call them at 877.650.0904.

[ Contribution: The TriZetto Provider Solutions editorial team ]