Sep 5, 2022 | Partner, Waystar
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.
Jun 12, 2022 | Partner, Waystar
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.
May 18, 2021 | Denied Claims, RCM Insight
Last month we looked at tools for getting clean claims out the door on the first try. Many billers or practices stop monitoring claims once the leave the practice management program, but this is where you are likely losing money. The unfortunate truth is you need to use the tools available to you to catch rejected and denied claims to ensure proper and timely payment. Today we will look at rejections and denials, and the resources you have (or need) to work efficiently.
The terms rejection and denial are used interchangeably in the billing world but they have distinct differences, including how you are notified. Let’s start with defining the differences.
- Claims can be rejected by the clearinghouse OR the payer
- Rejections are based on submission guidelines
- Rejected claims have not been entered into your payers system for adjudication
- Notified through a claim status report (ANSI 277) that comes back into most practice management programs from the clearinghouse
- Corrections do not require a resubmission code
- Claims are denied by your payer
- Denials are based on policy coverage
- Denials have been accepted for adjudication and deemed unpayable
- Notified on remittance advice (ANSI 835/ERA)
- Payers may require a resubmission code and original reference number when submitting a corrected claim
If you are using a clearinghouse and receiving your claim status reports electronically, you will be notified quickly about rejected claims. There are two ‘checkpoints’ that will look for errors. The first is your clearinghouse, the second is the payer.
At each checkpoint claims will be Rejected or Accepted, these status updates come to you through a claim status report. If your practice management system is able to process these reports (ANSI 277) your claims will be updated with the accepted or rejected information you will be able to correct any rejected claims within your practice management system. When you see an error, start with checking who has rejected your claim. This will be the point of contact if you have questions about the rejection or how to correct it. If you are not already, make it a daily task to get your reports, correct any rejected claims, and resubmit those claims.
When a claim has been accepted by your clearinghouse and the payer it enters the adjudication system. This is where the payer will make a determination on payment based on the members coverage and your contract. The denials will appear on your remittance advice with a payment or as a zero dollar payment, indicating that they have reviewed your claim and they have determined no payment is applicable. If you are enrolled with you payer for electronic remittance advice (ERA) this file will come electronically and your practice management system will be able to list or identify denied claims. These claims will either need to be researched further for clarification on the denial or written off. It is vital that your practice management system can handle these scenarios appropriately so you do not lose money for payable services.
This is another scenario where technology can seem scary. However, efficiently monitoring and working is well worth the learning curve. If you are already sending electronically and not using the claim status report or electronic remittance advice – coordinate with your clearinghouse and practice management system to find out how these reports can save you time and money.
If you would like more information on creating workflows for rejections, denials, or enrolling with a clearinghouse, let RCM Insight help! Visit us at www.rcminsight.com to request a consultation.
[Contribution by Stephanie Cremeans with RCM Insight]
May 11, 2021 | Features, Medical Billing Software Blog
Can you add up the number of hours your billing team spent during any given week or month waiting on-hold with insurance companies to get patient billing information? Does your staff invest hours of their valuable time seeking out the smallest of details to get paid? Are you aware that integrated eligibility, through EZClaim’s medical billing software, can reduce that time on-hold to a fraction of the total?
It is estimated that the average biller can spend up to 2-hours on-hold just to get an insurance company on the phone. Add to that an average of 10 – 15 minutes to talk through a patient and most companies will only address one or two patients at a time. To add to it often there are multiple insurance companies to call. As you can tell you quickly have a considerable amount of time lost making phone calls. Instead of spending hours on the phone with insurance companies, make best use of your staff’s time by checking to see if you have the integrated eligibility feature in your billing software.
Getting started is as easy as getting set up with a clearinghouse (EZClaim clearinghouse partners). Once you are signed up with a clearinghouse for the electronic claim submission program, they will have an integrated eligibility feature that is integrated into EZClaim. Once you sign up with this feature, you can send a batch request of 50 patients at one time and if needed, send multiple requests in a day. Do this by selecting an active patient list collectively or send them individually in smaller amounts. Either way the time savings will be exponential.
Eligibility response reports often come back within seconds making the process nearly real-time. When a response comes back you have the real-time eligibility information. You will get details on if they are covered or not, their active dates, deductibles, co-insurances, co-pays, and what amounts they are subject to and what will be deducted. With EZClaim eligibility integration built in you save valuable time. To learn more contact EZClaim’s website, email, or call 877.650.0904.
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, email them, or call them today at 877.650.0904.
Apr 5, 2021 | Claim Status Inquiry, Claims, Denied Claims, RCM Insight
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 ]