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 ]
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 paymentssystem 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.
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, visitEZClaim’s website,e-mail them, or call them today at 877.650.0904.
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 growing. A 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.
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, apartner 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.
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.
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.
There are five ‘phases’ in the life cycle of a medical bill: Pre-appointment; Point of care; Claim submission; Insurance payment or denial; and Patient payment. This post will overview each of these phases, and could even be considered to be a “101-level” course on Revenue Cycle Management.
The revenue cycle is the series of processes around healthcare payments—from the time a patient makes an appointment to the time a provider is paid—and everything in between. One way to think of it is in terms of the life cycle of a medical bill. Although there are many ways this process can play out, this post will lay out a common example below:
1. Pre-appointment For most general care, the first stage of the revenue cycle begins when a patient contacts a provider to set up their appointment. Generally this is when relevant patient information will begin to be collected for the eventual bill, referred to on the financial side of healthcare as a claim.
At this point a provider will determine whether the appointment and procedure will need prior authorization from an insurance company (referred to as the payer). Also, the electronic health record (EHR) used to help generate the claim is created, and will begin to accumulate further detail as the provider sends an eligibility inquiry to check into the patient’s insurance coverage.
2. Point of care The next step in the process begins when the patient arrives for their appointment. This could include when a patient arrives for an initial consultation, an outpatient procedure, or for a follow-up exam. This could also include a Telehealth appointment.
At any of these events, the provider may charge an up-front cost. One example of this is a co-pay, which is the set amount patients pay after their deductible (if they are insured), however, there are other kinds of payments that fall into this category, too.
3. Claim submission After the point of care, the provider completes and submits a claim with the appropriate codes to the payer. In order to accomplish that, billing staff must collect all necessary documentation and attach it to the claim. After submitting the claim to the payer, the provider’s team will monitor whether a claim has been been accepted, rejected, or denied.
[ Note: Medical coding refers to the clerical process of translating steps in the patient experience with reference numbers. The codes are normally based on medical documentation, such as a doctor’s notes or laboratory results. These explain to a payer how a patient was diagnosed and treated, and why. This information helps the payer decide how much of an encounter is covered under any given insurance plan, and therefore how much the payer will pay. ]
4. Insurance payment or denial Once the payer receives the claim, they ensure it contains complete information and agrees with provider and patient records. If there is an error, the claim will be rejected outright and the provider will have to submit a corrected claim.
The payer then begins the review process, referred to as adjudication. Payers evaluate claims for accurate coding and documentation, medical necessity, appropriate authorization, and more. Through this process, the payer decides their financial obligation. Any factor could cause the payer to deny the claim.
If the claim is approved, the payer submits payment to the provider with information explaining details of their decision. If the claim is denied, the provider will need to determine if the original needs to be corrected, or if it makes more sense to appeal the payer’s decision.
Following adjudication, the payer will send an explanation of benefits (EOB) to the patient. This EOB will provide a breakdown of how the patient’s coverage matched up to the charges attached to their care. It is not a billing statement, but it does show what the provider charged the payer, what portion insurance covers, and how much the patient is responsible for.
5. Patient payment The next phase occurs when the provider sends the patient a statement for their portion of financial responsibility. This stage occurs once the provider and payer have agreed on the details of the claim, what has been paid, and what is still owed.
The last step occurs when a patient pays the balance that they owe the provider for their care. Depending on the amount, the patient may be able pay it all at once, or they might need to work with the provider on a payment plan.
The above example represents one way the lie cycle of a medical bill can play out. Some of the ‘phases’ are often repeated. Because of the complexity of healthcare payments and the parties involved, there is not always a ‘straight line’ from patient care to complete payment. That’s why we call it the revenue cycle, and there are companies that provide systems for its management.
One of EZClaim’s partners, Waystar, aims to simplify and unify healthcare payments. Their technology automates many parts of the billing process laid out above, so it takes less time and energy for providers and their teams, and is more transparent for patients (Click here to learn more about how Waystar automates manual tasks and streamlines workflows.) When the revenue cycle is operating at its most efficient, providers can focus their resources on improving patient care—and that’s a better way forward for everyone!
For more information of how Waystar works together with EZClaim, click here.
[ Article and image provided by Waystar ]
ABOUT EZCLAIM: EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support, and can help improve medical billing revenues. To learn more, visit their website, e-mail them at email@example.com, or call a representative today at 877.650.0904.
Today’s healthcare landscape faces truly unprecedented challenges, which means it’s more important to get the most out of your analyticsto develop more informed, strategic decisions. 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: A “Trigger,” or the point in your revenue cycle that sets up the call for deeper analysis; “Interpretation” of data to determine root causes and identify appropriate next steps; “Intervention” to improve specific metrics; and “Tracking” of said metrics to chart success in achieving desired outcomes.
So, let’s examine what a successful version of each stage looks like:
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.
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.
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.
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.
Wrap Up A strong analytics solution does more than deliver a more fully developed picture of your revenue cycle performance. It provides actionable business intelligence, cuts down on time between analysis and action, and lessens the strain on your IT department.
Waystar is a ‘partner’ of EZClaim, and provides analytics for a practice using their medical billing software. For more details about EZClaim’s products and services, visit their website: https://ezclaim.com/
To learn more about how Waystar can help you harness the power of your data, call their main office at 844-4WAYSTAR, or call sales at 844-6WAYSTAR.
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