Switching to Electronic Claim Attachments
One of the biggest strains on the healthcare industry remains its reliance on paper and manual processes. The combination often adds up to human errors and costly denials, which require exponentially more time and resources to resolve, if left unchecked.
Among the manual processes most challenging to manage is claim attachments, which demand considerable time for teams to review requirements, collect and send necessary documentation, and complete follow-up procedures. According to the CAQH Index, the medical industry spent $590M annually exchanging attachments, with some providers spending anywhere between 10-30 minutes manually submitting an attachment to a payer.
An electronic claim attachments solution bolsters efficiency, strengthens cash flow, and significantly reduces AR days. If you’re considering how such a solution could benefit your healthcare organization, read on to learn about three key areas it can improve.
- Simplify document + data exchange with payers
Despite technological advancements, providers still face a complex, manual environment for payer document and data exchange. Electronic claim attachments can help ease long-standing friction points between providers and payers by automating supporting documentation submission. It’s a win-win for providers and payers as workflow efficiency can be maximized and claims adjudicated more swiftly and correctly.
- Support frictionless and remote workflow
Processing claim attachments becomes exponentially more time-consuming and expensive because of its paper-based nature and the need to keep up with ever-changing payer rules and requirements. Shifting to electronic claim attachments can provide flexibility to ensure your billing team can continue to operate effectively even in disruptive times. It not only saves time and money each day but it’s also proved critical during events like Covid-19, allowing a divided workforce to still get the job done.
- Reduce cost to collect
Not all clearinghouses are created equal—the right partner fervently seeks opportunities for staff to work smarter, not harder. Automation and scale are key elements to not only maximize efficiency and accuracy but also reduce a provider’s cost to collect.
Although electronic attachment adoption remains low, there’s considerable benefit to implementation. While electronic transaction for claim attachments has not yet been federally mandated, the 2020 CAQH Index found the medical industry could save over $377M per year, helping organizations protect their bottom lines and provide more affordable care to their patients and communities.
Wrapping it up: taking the smarter approach to submitting attachments
Providers are all under cost and reimbursement pressure and the need for smarter, purpose-built automation is the secret ingredient for remaining in the black. Electronic claim attachments are a simple way to take the administrative waste out of your processes, prevent costly denials and accelerate cash flow, all the while supporting a remote workforce.
Looking for a smarter, simpler way to manage claim attachments and streamline workflows? Find out how Waystar can help automate the process, reduce denials and accelerate reimbursement. Visit Waystar.com.
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.
A version of this guide to reducing back-office denials originally appeared on Waystar’s blog.
The last few years have been hard for just about everyone involved in healthcare, and not just because the revenue cycle has grown more complex. According to data from the Bureau of Labor Statistics, people on average now hold 12.4 jobs from age 18 to 54—nearly half of which are held before the age of 25. And that equates to just as many changes in their insurance coverage. Providers in turn must struggle to keep up with their patients’ seemingly ever-changing eligibility status, along with the details of what coverage is offered per level for a variety of payer plans. All that means it’s more challenging than ever to manage just about every aspect of the revenue cycle, and denials are no exception.
A recent MGMA poll found 69% of respondents had seen a noticeable increase in denials in 2021. Among those respondents, the average increase in denials was about 17%. And while there are plenty of reasons to explain the increase, we took the opportunity with our upcoming white paper, “Supercharge eligibility + estimates with a better payer intelligence engine,” to assess how eligibility-related denials factor into the equation.
How eligibility issues stir up more denials
Some of the results produced while developing that white paper were striking. When benchmarking denials for two similarly sized health institutions (both with similar patient populations and payer mix) we discovered a sizable difference in denial rates, one that indicated the first provider had processed millions less in denials. Further analysis revealed this provider dealt with roughly 35% fewer denials, which ultimately helped contribute to an additional $3-4M in revenue.
Generally, we expect such a discrepancy to be explained by a handful of familiar factors: a low clean-claims rate, an abundance of late filing or an escalating number of appeals left unattended to—issues normally associated with back-office management. But in this case those common factors did not dominate the narrative. Instead, the following stood out as the top drivers and differences between the two:
- A $39M difference in denials for patients identified as “not eligible”
- A $34M difference in denials related to coordination of benefits
- A $4M difference related to benefit maximums being exceeded
When we began to examine those discrepancies more closely, it became clear that there really wasn’t a back-office problem at all. In fact, client processes were considered quite lean and operated with consistent accuracy. Instead, problems were being generated much earlier in the rev cycle. By the time registration, scheduling and services had been rendered, there had not been notable mitigation to denial risks that should’ve been flagged. And with ever growing payer payment adjudication cycles, it seemed a steadily increasing denial rate was inevitable.
Looking for a root cause
In a study of Waystar clients, we found more than 10% of all registrants selected the wrong plan, and up to 35% of accounts triggered some kind of eligibility alert that indicated a potential denial risk. In other words, a significant portion of denials are caused by eligibility issues, one that could have been identified well in advance of them becoming problems. Finding other payers on file, replacement plans, CHIP, dental-only coverage and many other risk categories were simply not captured or flagged, which would have allowed end users to remediate the risk before a patient had even arrived for their appointment.
But what makes identifying these risks such a challenge? Ultimately there’s more to the problem than administrative oversight. The electronic data interchange (EDI) that makes modern eligibility solutions possible often includes message segments, plan codes and other critical identifying data that needs to be normalized and extracted. But that’s not possible without the right tools. If your front-end solution is not effectively crawling eligibility responses for risks like these, it’s time to upgrade your toolset and update your strategy.
Eligibility related denials are not always caused by issues in the coverage detection process, either. When it comes to common, multi-payer scenarios, benefit levels and coordination regularly cause problems in the claims adjudication process and ultimately have a significant impact on denial rates.
Older EDI solutions do not fully comprehend payer logic and often have a hard time identifying levels of coverage across different services. It’s no longer possible to rely on something like a ‘single STC 30’ EDI call to yield the benefit it (literally) once did. Now these benefits must be presented in a manner that lets staff easily interpret coverage and realistically determine when to expect payment from the patient and payer.
Wrapping it up: developing a comprehensive approach
You could be missing your single largest opportunity to strengthen your revenue cycle without a comprehensive approach to patient access eligibility. And one of the most important aspects of a truly comprehensive approach is shoring up your front-end processes to reduce the number of issues a claim might encounter as it moves downstream through the revenue cycle. Not only does this enhance the patient experience, it steadies revenue flow as it cuts down on the sort of trouble that would otherwise further drain staff time and resources.
Check out our most recent whitepaper, “Supercharge eligibility + estimates with a better payer intelligence engine,” for a more comprehensive look at what we’ve covered here. If you’re ready to tackle the challenges afflicting your front office, check out Waystar’s Financial Clearance solutions, which offer a smarter, simpler way to streamline areas like eligibility verification and prior authorization.
Join Waystar + EZClaim on July 14th to learn how to outsmart your denials.
If a medical billing program has “scrubbing,” why did my medical billing claim still get denied? It is a common question that we are going to answer today.
First, let’s get a better understanding of the words we are talking about. In the medical billing world, validation and scrubbing tend to be used interchangeably. While they are similar – they are not actually the same. Understanding what you have and what you need will help you submit ‘clean’ claims.
According to Technopedia, data validation checks for the integrity and validity of data and ensures the data complies with the requirements. So, what requirements? Often people assume that this means payer requirements, but that is typically not standard. Validation rules are built into your practice management software and can be used for several points. Following are some common rules you may find in your program:
- Ensure NPI‘s and Tax IDs are the appropriate lengths
- Ensure patients date of birth is entered
- Ensure that a procedure code and place of service are present on each claim
While these scenarios are standard across the industry, there may be other situations that a validation rule can help. Some programs will allow you to create custom rules for your practice. A customized validation rule will allow you to create a rule for a payer requirement. For instance, you could create a rule to prevent the following:
- Do you have a code that always requires a modifier, but only for a specific payer?
- Work with pediatrics and always need the ‘relationship to insured’ to read something other than self
- How about insurance ID numbers that are a specific alpha-numeric combo, like 3 letters followed by 9 digits?
Keep in mind, if you are creating validation rules the program will make sure that the criteria are met based on the rule entered into your software. When creating custom rules, it is important to note that this will not verify payer billing guidelines. You will need to obtain information directly from your payer to create a rule that coincides with their policies.
Once any validation errors have been addressed your claims will go to the clearinghouse you are working with. Most clearinghouses offer claim scrubbing for an additional fee. Technopedia defines data scrubbing as the procedure of identifying and then modifying or removing incomplete, incorrect, inaccurately formatted, or repeated data.
Claim scrubbing is available in several ways. It may be used within your practice management system, your clearinghouse, or even a third-party vendor. Claim scrubbing services can vary greatly in what they are looking for.
Once the claim has left your practice management system it will likely go through at least 2 scrubbing programs—one with the clearinghouse and one with your payer, prior to accepting the claim for processing. When claims are found to have an error, these results are sent back through a Claim Status Report (ANSI 277 file or a human-readable text file). This report will include information about why the claim cannot be processed. This report will also indicate whether it is the clearinghouse or the payer that is rejecting the claim. If you have further questions about the rejection, you will need to contact the entity that has rejected it.
Checking the Claim Status Reports on a regular basis will help you correct the errors and resubmit in a timely manner. In addition, the information you have gathered from the rejections can be used to update internal processes or create customized validation rules to prevent future rejections for the same error–saving you time and money!
RCM Insight is a medical billing company that uses EZClaim’s medical billing software. For any details that have to do with claims validation and “scrubbing,” contact RCM Insight directly.
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 by Stephanie Cremean’s with RCM Insights ]
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.
With high deductible health plans on the rise, the recent explosion of telehealth appointments due to COVID-19, and many other factors in play, it’s more important than ever for everyone to understand the life cycle of a medical bill, and how the process works. The healthcare revenue cycle is relevant not only to those who work in healthcare, but to the patient, too.
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:
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 ]
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.
In the wake of the COVID-19 pandemic, Telehealth adoption has exploded, and there are six revenue cycle metrics to track.
Many patients are prohibited or reluctant to venture out for on-site care. The combination of relaxed regulations and expanded payment parity for appointments has made virtual meetings easier and more attractive for providers, who are turning to these technologies to stay engaged with patients—and maintain cashflow. Dr. Robert McLean, a former president of the American College of Physicians, recently said, “this crisis has forced us to change how we deliver health care more in 20 days than we had in 20 years.”
A new industry report predicts that the number of Telehealth visits in the US will surpass one billion by the end of the year, and speculates that nearly half of those visits will be related to COVID-19. At Waystar, we have been closely monitoring claim trends and are seeing this growth firsthand. In fact, the volume of Telehealth claims on the Waystar platform has grown by more than 100 times since mid-March. On two particular days in late April, they accounted for more than 15% of our total daily claim volume. Before COVID-19, they would have accounted for less than one percent!
For many providers, this shift will require new revenue cycle strategies to meet growing patient demand without overwhelming clinicians and administrative teams—or already strained operating budgets. It’s important to remember this is still very much an evolving care delivery model with the opportunity for errors on the part of both payers, providers, and administrative staff. For this reason, revenue cycle professionals should diligently monitor claims to ensure proper adjudication, identify learning opportunities, and uncover areas for operational improvement.
Below, we’ve listed six core Telehealth-related metrics you should regularly track to ensure billing accuracy, maximize payer reimbursement, and reduce claim rejections and denials. For more on how to best navigate the evolving telemedicine landscape, check out our resource hub here.
To report on Telehealth-related claims, you’ll first need to identify and isolate claims containing Telehealth procedure codes. See CMS’ Telehealth code list to identify the specific procedure codes and modifiers that apply to your organization.
1. Payer Telehealth claim rejections by volume and/or billed amount
2. Payer Telehealth claim denials by volume and/or billed amount
If your Telehealth claims are being denied or rejected, do you know which specific payers are doing so at the highest rate? Drill down to discover the specific reason codes payers are attaching to rejections and denials so you can better understand payer-specific rules and avoid these oversights in the future. In some cases, you may identify trends that warrant a call to the payer to correct.
3. Telehealth claim volume by the provider
Review this claim volume by individual provider. If you notice providers within your organization generating a much lower volume of Telehealth claims than peers, perhaps they could benefit from additional training on Telehealth technology and use cases.
Ensuring Billing Accuracy:
4. Telehealth claim rejections by biller/team
5. Telehealth claim denials by biller/team
Are certain billing personnel or teams producing higher denial or rejection rates than others? Keep a close eye on these trends and remember most of this is new for everyone. If some team members are seeing more rejections or denials than they should, it could be a great opportunity to hold training and collaborate on strategies for success.
6. Telehealth claim volume by procedure code
Which Telehealth codes are you using? Each code reimburses at a different rate, so choosing the wrong ones could leave money on the table. Be sure to read up on CMS’ requirements (check out their fact sheet and code list) to ensure you’re choosing the appropriate code(s) on each Telehealth claim.
You have all the data you need to drive informed decision making and improve financial performance—you just need the right analytics tool in your corner. Our new Waystar Analytics solution offers a pre-built Telehealth dashboard that can help you easily interpret, share all the metrics above, and track these revenue cycle metrics. Click here to learn more about Waystar Analytics and how it can deliver the insights you need during this time of transition.
[ By Waystar ]