Achieving a Stronger Denial and Appeal Management Strategy

Achieving a Stronger Denial and Appeal Management Strategy

Waystar’s newest guide investigates the state of denials and appeals in today’s healthcare landscape and explores how today’s most successful providers are redefining the core components of their denial and appeal process to grow revenue, streamline workflows and revitalize their approach to the process.

Denial and appeal management today

Like many administrative tasks further burdened by the impacts of the COVID-19 pandemic, denial and appeal management workflows dependent on manual processes are experiencing new strains on accuracy and productivity.

Last year a survey investigated how billing and administrative tasks were impacted by COVID-19, with 37% of surveyed providers reporting an increase in workloads due to issues with coding and requirements. An assessment of the general industry outlook found claim denial rates are at an all-time high, with 33% of surveyed hospital execs reporting concerns they are entering a “denials danger zone,” where rates grow to 10% or more.

Estimates put the cost of reworking denials as high as 20% of rev cycle expenses because on average they cost 4x as much to process than the initial claim. With so much strain already present on providers’ resources, many are turning to automation to ease the burden.

How automation elevates the process

Once a provider has been notified of a denied claim, steps are taken to identify whether or not it can be appealed. Many of the errors that cause denials come down to administrative issues that took place at the start of the claim lifecycle.

A recent analysis found 86% of the denials processed between July 2019 and June 2020 were avoidable. Analysis indicated that many of those issues stemmed from front-end errors related to benefit information, coverage detail, and shortcoming related to missing or invalid claim data.

While there’s a wide mix of problems that could cause a denial, with different providers experiencing a diversity of challenges depending on their location and patient population, they all face a common hurdle: the burden of manual denial management and appeal procedures put on administrative staff.

Like many other administrative processes, providers for the most part rely on a mix of manual and electronic procedures to handle denial and appeal management. But the industry’s continued reliance on manual procedures is beginning to have a negative effect.

How providers are transforming their approach to denial + appeal management

Studies have found that it costs about $118 in reworking fees to appeal a denied claim. These costs are exacerbated by the industry’s overall reliance on manual processes—a systemic issue many recognize yet fail to capitalize on. Indeed, while many providers see the promise automation can deliver on, they still face a number of considerations before pushing forward with implementing an automated solution.

And automation is a hot topic for providers for a very good reason—studies have demonstrated the US healthcare system could save as much as $16.3B by automating old or outdated processes. When it comes to denial and appeal management, the benefits are far-reaching, from improvements to productivity and a reduced strain on resources to huge boosts to claim accuracy and revenue recovery.

What to look for in a denial + appeal management solution

Leading-class solutions offer a wide selection of tools to provide a comprehensive approach to denial and appeal management, using customized, exception-based workflows to streamline the entire process and overturn a sizable increase in denials.

The appeal toolset a solution offers should make it easier to coordinate and use the info and data necessary to automatically process appeals and recover cash that would otherwise create productivity issues or unnecessary fees.

The solution’s ability to prioritize appeals based on cash value automatically lets staff concentrate on tasks that actually demand their attention, supporting them with additional tools like automatically generated payer-specific appeal forms and robust analytics capabilities that allow you to track and measure progress and problem areas.

Keeping disruptions at a minimum is key when considering your solution as well, so consider its ability to work efficiently with your existing systems and look for a partner that can demonstrate a strong history of seamless integrations.

Wrapping it up: why denial + appeal management solutions matters

A recent Waystar survey found 76% of providers categorized denials as their biggest RCM challenge. And the wider picture of healthcare reflects an industry struggling to solve a long-standing problem with manual processes and few answers.

Implementing an automated denial and appeal management solution is quickly becoming the optimal path forward for most providers, even if many have apprehensions about committing to the switch. But as new innovations cut down on the resources and time needed to implement the tech, the time is quickly approaching where the switch will be easier, and more vital, than ever before.

Click here to find out how Waystar can help fully automate the process and help you recover more revenue while reducing the burden on staff.

Heading to AMBA in October?  Visit Waystar and EZClaim while you’re there!  Stay tuned for more event details.


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 Waystar ]

4 Steps to Getting the Most Out of Your Data Analytics

4 Steps to Getting the Most Out of Your Data Analytics

As patients return to doctor’s offices and health systems around the country, healthcare organizations find themselves in uncharted waters, with a greater need than ever to make data-driven decisions that grow revenue. Per a recent report from KLAS, 63% of hospitals found themselves struggling with real-time data analytics.

It should come as no surprise then that investments in new analytics tech and training are on the rise. According to a report from the Society of Actuaries (SOA), 42% of surveyed healthcare executives reported an improvement in patient satisfaction since implementing predictive analytics, while 39% said they had cut costs. Since 2011, over $39B has been invested in digital health tech, including $7.48B in 2019 alone. It’s estimated that roughly 20% of that has been funneled into the development of technology-focused on managing health records and analytics. Furthermore, some models have estimated improving available data collection and analysis tech could save the healthcare industry roughly 25% of its total costs.

The question is, what can you do to unlock that potential within your own organization? There’s a deep well of data that each revenue cycle feeds into, which if properly analyzed, can help organizations operate at their most efficient and effective. Here are the four stages of data analytics workflows that are key to developing those actionable insights.

1. A trigger, or the point in your revenue cycle that sets up the call for deeper analysis
2. Interpretation of data to determine root causes and identify appropriate next steps
3. Intervention to improve specific metrics
4. Tracking of said metrics to chart success in achieving desired outcomes

Let’s examine what a successful version of each stage looks like.

1. Trigger
The trigger occurs when you notice something that needs further investigation. With the right analytics tool, you can easily access all of your key performance indicators, financial goals, and more, providing the visibility you need into your rev cycle. When something looks amiss or needs improving, you can drill down to the level that shows what’s really going on.

2. Interpretation
Even a wealth of data amounts to nothing without an efficient way to process and communicate key takeaways. You’ll need to equip your team with access to concise reports, smart visualizations, and relevant historical data in order to get them to the insights that drive action.

3. Intervention
Now is the time to take action. Intervention is ultimately tied directly to your ability to drill down into the data underlying problematic areas of your revenue cycle and clearly communicate takeaways with your team. Success at this stage depends on designing a plan based on your best understanding of underlying issues and the most effective way to address them.

4. Tracking
Your intervention plan is built on KPIs that naturally intertwine with the way you measure success across your revenue cycle. With proper implementation and tracking, running with the analytics cycle can become a simple addition to your everyday workflow. More than delivering on your initial goals, the true power of analytics is the ability to deliver repeat value on your initial investment.

A strong analytics solution does more than deliver a more fully developed picture of your rev cycle performance. It provides actionable business intelligence, cuts down on time between analysis and action, and lessens the strain on your IT department.
Beyond the actionable internal insights it can provide, analytics is also a key tool for helping you benchmark performance in comparison to peers in the industry. And with the right analytics solution, competitive analysis is a simple task, using automation that reviews customizable benchmarks for a tailored review of the claim, payment, and denial performance.

Looking for a truly comprehensive analytics solution to help improve performance and enhance your benchmarking capabilities? Find out how Waystar can help you harness the power of your data through analytics. Visit Waystar.com

Heading to AMBA in October? Visit Waystar and EZClaim while you’re there! Stay tuned for more event details.


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 WayStar ]

Defeat Medical Claim Denials With Data

Defeat Medical Claim Denials With Data

For many providers, medical claim denials are one of the single biggest drains on revenue. When you consider that working just one denial costs about $25, knowing why claims are being denied and how to prevent them in the future isn’t a luxury—it’s a necessity.

Automation and advanced analytics can take much of the burden off your billing team by helping you identify potential denial triggers, adapt to constantly changing payer guidelines, and uncover actionable trends in your claim data.

Waystar’s Denials by the Numbers:

  • 5-10% average denial rate amount physician practices
  • 90% of denials are preventable
  • 76% of providers say denials are their biggest RCM challenge

[ Note: View or download Waystar’s “Defeat Denials with Data” white paper here ]

Waystar, a partner of EZClaim, integrates easily with its medical billing software, creating a seamless exchange of claim, remit, and eligibility information. To learn more about defeating medical claim denials, or to add Waystar as your clearinghouse, visit this page.


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 and white paper contributed by Waystar ]

Medical Bills and the Price Transparency Rule

Medical Bills and the Price Transparency Rule

New Patient Survey About Price Transparency Rule

With the cost of insurance premiums and deductibles both on the rise, patients have begun taking on greater responsibility for paying for healthcare than ever before. In return, they are becoming more discerning shoppers and expect more from the patient experience that their providers are delivering. One of the biggest steps that have been taken to create a more standardized, consumer-like experience is the introduction of the final price transparency rule from the Centers for Medicare and Medicaid Services.

More than half of consumers have received an unexpected medical bill

Despite the $3.81 trillion that was spent on healthcare in 2019, America’s healthcare payments system has long remained opaque and broken. Patients are frequently faced with unexpected or surprisingly high medical bills, discover too late that a provider they’d been told was in-network was actually out of network, and are forced to wait 60-90 days to receive their medical bills.

Patients are more concerned about billing than the quality of care

In October 2020, Waystar surveyed 1,000 consumers about their experiences with medical bills, and awareness and attitudes towards the upcoming price transparency rule. More than half of respondents have received an unexpected medical bill, meaning that they assumed a service was covered by insurance and it ultimately was not, or the amount they expected to pay out of pocket was different from the bill they received.

> > > CLICK HERE To Read the Results of the Waystar Survey < < <

 


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 Waystar ]

4 Tips To Reducing Claim Denials in 2021

4 Tips To Reducing Claim Denials in 2021

Reducing claim denials has long been a challenge for providers. In the worst case, denied claims end up as unexpected—and sometimes unaffordable—bills for patients. The challenge only seems to be growingA recent survey conducted by the American Hospital Association (AHA) found that 89% of respondents had seen a noticeable increase in denials over the past three years, with 51% describing the increase as “significant.”

Minimizing loss will be top of mind for providers as the COVID-19 pandemic continues to put a strain on their resources, and minimizing or preventing denials will need to be a core part of that strategy. With that in mind, we’re offering four tips to help guide revenue cycle strategies for better denial reduction in 2021.

 

1. Analyze and Assess

In order to achieve and maintain a healthier denial rate, it’s vital to have a good handle on the factors creating problems in the first place. Keep the following in mind as you start to structure your analysis:

  • Review key performance indicators: Take a look at which metrics are being used to benchmark success or failure and see if it’s time for a refresh
  • Evaluate workflows: It’s important to have a clear understanding of how your team operates, and that you can detail workflows as step-by-step processes
  • Assess tools: Inventory the software you’re using and discuss with your team how it helps or hinders them
  • Staff efficiency: Consider the number of team members and resources involved in each step of the denial management process

It’s also important to talk to staff. Your team can offer invaluable insight on what is and isn’t working to help you develop a more comprehensive understanding of the shape and scope of the systemic issues contributing to your denial rate.

2. Reduce Errors Upfront

Eligibility, registration, and authorization errors remain the greatest cause of denials and write-offs, so a good first step is to focus on being proactive instead of reactive. Often, it’s easy to get into a routine where errors are only addressed after they occur. But incorporating tech to verify coverage and benefit accuracy in advance can lead to higher efficiency and much less manual labor spent to correct those issues later on.

Similarly, a recent AHA report found a failure to obtain prior authorization to be one of the most common reasons for a claim to be denied by a commercial health plan. In another recent survey, the American Medical Association found that 86% of providers surveyed were struggling with a high administrative burden created by prior authorizations.

Recent innovations have made the process simpler than ever. The right prior authorization solution can automate the process and make it simpler, smarter, and much less labor-intensive, reducing manual input errors and preventing denials.

3. Cut Down on Manual Labor

Claim denials are often the result of staff trying to keep track of a seemingly overwhelming number of rules and regulations while juggling various systems and filing requirements. When your staff is overburdened, it’s that much easier for them to make simple errors or miss deadlines.

There are numerous tools available for teams who are either struggling with paper-based processes or databases without automation. With an AI-powered solution, you can streamline a number of time-consuming tasks while simultaneously automatically ensuring you’re identifying missing data or claim errors that can be corrected before they’re submitted.

It’s also a good idea to review any potential new tools with your team. Their insight will help you properly determine which solutions will actually improve their workflows, and which could prove an expensive time sink.

4. Use Stronger Reporting Tools

Accurate and in-depth reporting should be core to your strategy. Effective reporting tools let you quantify and assess the issues that influence your denial rate, allowing you to easily spot persistent workflow errors or other systemic problems that can create extra work or strain resources.

New tools powered by AI and machine learning offer more robust reporting options than ever, with advanced analytics and visualization capabilities that make it easy to explore complex data sets or identify trends. Mountains of information can now be easily managed and measured, giving you access to operational insights that will help you better understand problem areas and identify opportunities for improvement.

 

The Wrap-up

With the right tools, a solid strategy, and expert guidance, you can take a proactive approach to reducing claim denials. Our automated tools make it easy for your team to streamline their workflows while reducing errors and administrative costs. With Hubble, our AI and RPA platform, you can unlock the insights you need to reduce your denial rate and increase cash flow.

Waystar, a partner of EZClaim, also offers a number of front-end solutions to help you take a more proactive approach to your denial rate.  Click here to learn more about how Waystar can help you with reducing claim denials and claim management. For more information about Waystar’s platform, visit their website, or give them a call at 844.492.9782.

To find out more about EZClaim’s medical billing software, visit their website, e-mail their support team, or call them at 877.650-0904.

[ Contribution: Waystar ]

Big Changes Coming for Medicare Advantage

Big Changes Coming for Medicare Advantage

With Medicare Advantage enrollment continuing to rise and more plans offering more benefits than ever, big changes are coming in 2021. This post will discuss the key changes to Medicare Advantage plans in the next year, program updates due to the COVID-19 public health emergency, and advice on how to navigate billing and reimbursement concerns.

For the first time in history, Medicare Advantage (MA) penetration has reached 40% of the total Medicare-eligible population. Currently, 25.4 million people are enrolled in Medicare Advantage (MA) plans, with a total Medicare-eligible population of 62.4 million, according to the Centers for Medicare and Medicaid Services (CMS). [ Link to report ]

With an aging population, enrollment in Medicare Advantage plans will only continue to grow (The Congressional Budget Office projects enrollment in these plans to rise to about 51% by 2030).

Medicare Advantage is an alternative to traditional Medicare that acts as an all-in-one health plan and is sold by private insurers. All Medicare Advantage plans must provide at least the same level of coverage as original Medicare, but they may impose different rules, restrictions, and costs. Most Advantage plans offer the same A and B coverage for the same monthly premium as regular Medicare plans, but also often include Part D prescription drug coverage, limited vision, and dental care, broader coverage, lower premiums, maximum out-of-pocket limits, and extra benefits—all of which expanded in 2020.

While this represents a distinct opportunity for many providers to be more profitable, growing enrollment also poses challenges. Medicare beneficiaries have more choice than ever before when it comes to selecting an MA plan.

According to the Kaiser Family Foundation (KFF), there are 3,148 Medicare Advantage plans available for individual enrollment for the 2020 plan year—an increase of 414 plans since 2019. The average beneficiary could choose among 28 plans in 2020. While the choice is great for the beneficiary, it adds complexity to healthcare providers’ revenue cycles, who need to navigate hurdles that vary by the plan in order to get reimbursed.

MA plans also tend to be more transient, meaning patients may switch often, even yearly if they choose through the open enrollment period. Providers must better manage every patient accordingly so they can maximize plan benefits. Doing so takes more effort, but the payoff can lead to profit.

CMS has clearly stated a goal to move from the current fee-for-service models toward value-based care. While the Medicare Advantage population grew by 60% from 2013 to 2019, the fee-for-service Medicare population only grew by 5%. The progress Medicare Advantage plans have achieved essentially creates an idea marketplace for beneficiaries. Enrollment costs are down and more plans than ever are offering new, innovative benefits. But what does this mean for providers?

So, how has COVID-19 affected Medicare Advantage plans? Well, the COVID-19 stimulus package, the Coronavirus Aid, Relief and Economic Security (CARES) Act, includes $100 billion in new funds for hospitals and other healthcare entities. The Centers for Medicare and Medicaid Services (CMS) made $30 billion of these funds available to healthcare providers based on their share of total Medicare fee-for-service (FFS) reimbursements in 2019, resulting in higher payments to hospitals in some states than others, according to KFF. Hospitals in states with higher shares of Medicare Advantage enrollees may have lower FFS reimbursement overall. As a result, some hospitals and other healthcare entities may be reimbursed less than they would if the allocation of funds considered payments received on behalf of Medicare Advantage enrollees.

In response to the COVID-19 emergency, many Medicare Advantage insurers waived cost-sharing requirements for COVID-19 treatment, meaning that Medicare Advantage beneficiaries will not have to pay cost-sharing if they require hospitalization due to COVID-19 (though they would if they are hospitalized for other reasons).

If a vaccine for COVID-19 becomes available to the public, Medicare is required to cover it under Part B with no cost-sharing for traditional Medicare or Medicare Advantage plan beneficiaries, based on a provision in the Coronavirus Aid Relief, and Economic Security (CARES) Act.

 

A Spotlight on Prior Authorization
Medicare Advantage plans can require enrollees to receive prior authorization before service will be covered, and nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services in 2020, according to KFF. Prior authorization is most often required for relatively expensive services, such as inpatient hospital stays, skilled nursing facility stays, and Part B drugs, and is infrequently required for preventive services. Prior authorization can create barriers for providers and beneficiaries, but it’s meant to prevent patients from getting services that are not medically necessary, thus reducing costs for beneficiaries and insurers.

In a 2018 analysis, KFF found that four out of five MA enrollees—or 80%—are in plans that require prior authorization for at least one Medicare-covered service. More than 60% of MA plan enrollees require prior authorization before receiving home health services, and that percentage increases to more than 70% for skilled nursing facility and inpatient hospital stays.

The Families First Coronavirus Response Act (FFCRA) prohibits the use of prior authorization or other utilization management requirements for these services. A significant number of Medicare Advantage plans have waived prior authorization requirements for individuals needing treatment for COVID-19.

 

How Providers Can Prepare for a Medicare Advantage Boom
Medicare beneficiaries have more choice than ever before when it comes to selecting a MA plan. While the choice is great for the beneficiary, it adds complexity to healthcare providers’ revenue cycle. Healthcare providers will need to navigate new hurdles that vary by the MA plan in order to get reimbursed.

When beneficiaries change plans, it creates another challenge for providers. Historically, about 10% of MA enrollees change plans during open enrollment. Although this number seems low, even a small change in coverage can cause big problems for a healthcare provider’s revenue and cash flow. Billing the wrong insurance company leads to costly denials and appeals. Becker’s Hospital Review estimates that healthcare providers spend about $118 per claim on appeals. A study by the Medical Group Management Association found that the cost to rework a denied claim is approximately $25, and more than 50% of denied claims are never reworked.

Despite the challenges, providers don’t want to be left out of the MA boom. But how can they best prepare? Well, first off, healthcare providers need to ensure they are capturing accurate patient information. Next, they need to reevaluate workflows, so they are prepared to handle time-consuming prior authorizations. Additionally, healthcare organizations must consider how frequently they are re-running eligibility on patient rosters to make certain they do not miss a change in insurance coverage for patients under their care. Providers should re-run patient rosters monthly, so they have the most accurate benefit information. This will help them avoid unnecessary claim denials.

As MA continues to ramp up, the most successful providers will be those who work with a revenue cycle management partner that understands the nuances of Medicare reimbursement as well as the added complexities of MA.

With the acquisition of eSolutions, a leader in revenue cycle technology with Medicare-specific solutions, EZClaim’s ‘partner’, Waystar, so happens to be the first technology to unite commercial, government, and patient payments into a single platform, solving a major challenge and creating meaningful efficiencies. Billing Medicare, Medicare Advantage, and commercial claims from a single platform eliminates the hassle of managing multiple revenue cycle platforms and allows providers to get deeper AI-generated insights for faster reimbursement and increased value—for their organizations and their patients.

 

For more information about Waystar‘s platform, visit their website, or give them a call at 844.492.9782. To find out more about EZClaim‘s medical billing software, visit their website, e-mail their support team, or call them at 877.650-0904.

[ Article contributed by Waystar ]