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Preventing Revenue Loss through Effective Resource Management

Preventing Revenue Loss through Effective Resource Management

From the onset of the pandemic, burnout has been one of the biggest challenges facing healthcare workers. Beyond the physical aspect of being overworked and risking one’s own health to help those in need, there is also the toll the jobs takes on mental health. And burnout doesn’t only affect front-line workers. While nurses and doctors may face the brunt of pandemic-related woes, administrative burdens also impacts office staff and C-suite executives. It truly is a top-to-bottom issue.

This burnout, coupled with other issues like employee vaccine mandates and patients behaving badly, has no doubt taken its toll on healthcare workers. And the result? Resignations. Just as The Great Resignation rocked Corporate America, the healthcare industry has also felt the effects. It’s such an issue that industry CEOs ranked personnel shortages as the number one challenge they face, according to new survey results from the American College of Healthcare Executives. And the recent numbers do not lie. Hospitals lost 5,100 jobs in December 2021, according to the U.S. Bureau of Labor Statistics, with nursing and residential care facilities losing 6,100 jobs the same month, respectively. And it’s not just front-line workers that are resigning. The Medical Group Management Association (MGMA) claims 88 percent of medical practices have had difficulties recruiting front office staff.

Much of the operational tasks handled by front office employees are critical to the functioning of a practice – coding, scheduling, bill processing – need to be done regardless of staff limitations. Administrative burnout is real, and when there is an overall decrease in staff, the remaining employees are often left to pick up the slack.

Increasing costs and budgets

According to Mercer’s 2021 External Healthcare Labor Market Analysis, which examined predictive healthcare labor statistics over the next 10 years across all 50 states, labor shortages should be expected as the U.S works through the COVID-19 pandemic. With the issue of resignations and burnout not going away any time soon, leaders need to find ways to adjust. If healthcare employers want to gain and retain workers, money talks. While offering higher-than-usual salaries and additions like sign-on bonuses may not have been originally in the budget, it may be the right route to circumvent staffing issues. And as inflation and the overall cost of living rises, employers are finding that more money than usual may need to be allotted for payment increases too. A MGMA Stat poll found that fifty percent of healthcare practices budgeted more than usual for workers’ cost-of-living increases for 2022. With costs anticipated to rise, practices need to get ahead of their budgetary planning to put themselves in the best position, staffing-wise, to succeed in years to come.

Staffing the Practice of the Future           

One way that organizations are trying to navigate staffing issues is though flexibility. A 2022 MGMA poll found that 59% of medical group practices shifted workers to permanent and/or hybrid work in 2021. Said workers included roles like coders, call center representatives and administrative positions. One year after the onset of the pandemic, an MGMA Stat poll showed that one in five practices said that more than 25 percent of their workforce was remote at least half the time. One of the nation’s largest health systems, the Cleveland Clinic, currently has nearly 8,000 administrative employees in at least a partially remote work model. Leadership is seeing the advantages of remote work, including reduced overhead costs, more satisfied employees and the ability to cast a wider recruiting net that is no longer limited to a single geographic region.

Over the last two years or so, organizations witnessed the positive outcome of remote work and decided not to switch back to traditional models. Another, more proactive way to alleviate administrative burnout is to get things right the first time. The key to this is having the right technology in place, like claims management and eligibility verifications, that can increase automation and create the most efficient workflows. Business processing services, including end-to-end billing and credentialing services can alleviate manual work and automate processes. Outsourcing is another logical path to take when there is just not enough hands in-house to manage day-to-day tasks.

With remote work and outsourcing now seen as viable options, organizations must adjust to keep with the times. If the C-Suite wants to retain and recruit talent, finding solutions that are satisfactory for the employee and employer should be a top concern for 2022 and beyond. Overall, organizations need to meet the needs of their employees. These needs may be vast and varied, but most executives would agree that it centers on flexibility, connectivity and technology.

Organizations looking for assistance implementing automation and RCM resources can learn more about ways TriZetto Provider Solutions can help by visiting trizettoprovider.com/ezclaim.

Out-of-Network Services: How will the No Surprises Act impact payments?

Out-of-Network Services: How will the No Surprises Act impact payments?

While the No Surprises Act aims to address many issues involved in the patient price transparency process, a lot of attention will be put on out-of-networks charges. Many of the provisions will address how patients will be relieved of surprise medical bills from services that were rendered by providers outside of their insurance networks, and providers are wanting to know how to prepare for potential changes in their revenue. We detail how CMS has planned to address out-of-network payment disputes for emergency situations, as well as situations when services were non-emergent.

Emergency Out-of-Network Services

Providers will begin to see differences in reimbursements for emergency out-of-network claims. These will be paid using a ‘Qualified Payment Amount’. Payers are instructed to use different methods to determine the payment amounts, which will vary by the location of the service.

Dispute Resolution

Providers will need to be prepared to review these claims to see that they were paid appropriately or if there is a need to dispute the claim. If a dispute is in order, CMS provides a portal to initiate a dispute. Dispute resolution follows a strict timeline that goes as follows:

  • Submit Claim
    • After claim submission the health plan has up to 30 days to pay or deny
  • Negotiate Payment
    • Next, payers and providers have 30 days of claim payment or denial to negotiate
  • Initiate Dispute
    • Providers then have within 4 days of end of negotiations to initiate a dispute using the CMS Portal
  • Select Arbitrator
    • If no agreement come from the negotiations, one will be selected by CMS within 3 days
  • Submit Dispute
    • Within 10 days of arbitrator selection, provider and payers submit documentation and offer for reimbursement
  • Arbitrator Decision
    • The arbitrator then decides which offer to be paid within 30 days of the dispute
  • Final Payment
    • And final payment will be made within 30 days of the arbitrator decision

Non-Emergency Out-of-Network Services

The No Surprises Act prescribes that out-of-network patients will receive good faith estimates prior to receiving services at medical facilities. The act covers self-pay and uninsured patients, but may also include patients whose health plan does not cover the services to be provided, as well as patients who have benefits but are opting not to use them. Patients who receive a bill for services that differs from the estimate by more than $400 will have up to 120 days from receiving the bill to dispute the charges. Additional rulemaking will be forthcoming to define how provider and payer systems should interact to provide cost information for the estimate.

Keep abreast with updated regulations and the key points of the No Surprises Act (NSA) that could impact your revenue cycle by visiting TriZetto Provider Solutionsdesignated landing page. Subscribe to NSA news updates and explore solutions that equip you to have informed conversations about financial responsibility and eligibility.


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.

Automate Denial Management for Good

Automate Denial Management for Good

Denial management has been a thorn in the side of provider RCM teams forever.  And unfortunately, despite expanded EHR use and claim coding improvements, denial rates have continued to rise into the pandemic; from 9% in 2016 to 10.8% mid-pandemic in 2020.

Cost To Rework Claims

To make matters worse, the average cost of reworking denials ranges from $25-$118 per claim.  As a result, over 60% of denials are never resubmitted!  Here’s why:

  • Lack of A/R Specific Software: Payer and EHR variability has forced A/R into manual workflows
  • Staff Cost: Cost to retain skilled A/R follow up staff

Keys To Optimizing Denial Management

The good news is, modern software tools are easier to build and here to help provider billing teams.  Historically, only large hospitals and payers had access to the most advanced technology, but that’s changing rapidly.  Here are a few A/R follow up areas where modern software can help.

Auto-Triage of Claims

The current standard for all billing teams is to assess each claim one-by-one.  Typically, it’s an “ERA by ERA” assessment that often requires further digging to really determine the correct action.  However, payer claim decisions are pattern-based.  With modern tools that combine these patterns with your preferred triaging, the software can triage claims in batches.  This both removes the repetitive process of claim triage and optimizes the proper action decision.

100% Digital Appeals

Even after choosing to appeal a claim or send a medical record, the process of building an appeal letter, filling out a payer form, and then submitting it back to the various payers is extremely time consuming.  Some teams report that it takes 35 minutes per claim!

Finding the right language to best appeal the denial is challenging on its own.  What worked and what didn’t work — and why?  Billing agents are often left to themselves to figure this out.  From there, actually submitting the appeal via postal mail, fax, or payer portal is both time consuming, costly, and often requires a different team to touch the appeal.

Having a solution that turns this entire build and submission into a single, digital process for all denial types and payers is the only way to solve this major pain.

Team Performance Tracking

Without a digital A/R follow tool, described above, billing team managers are left to track their team’s performance through the use of onerous spreadsheets and difficult to assess reports.  Managers rely on their team members to train each other and report back any difficulties they might be experiencing.  This leads to real gaps in performance assessment and, ultimately, the ability to help their teams succeed.

Having a digital A/R solution fixes that.  The need for a real-time dashboard that provides these KPIs, along with real-time alerts related to individual agent performance, is the way forward.

Real-Time Denial Trends AND Alerts

Finally, as mentioned earlier, denials happen in patterns.  The challenge is, those patterns vary by payer, provider, region, and specialty.  And they change over time too!  So, these patterns are difficult to track manually.  Each pattern change has immediate downstream effects that can lead all the way back to the providers themselves, with annoying code corrections and medical records requests.

A modern A/R solution that is dedicated to sharing these patterns via a real-time dashboard is the key.  Not just a static dashboard with denial statistics, but in-app and email alerts that indicate an important change in a pattern.  That aspect is especially important, because all billing agents are extremely busy and are bogged down by task after task.  A smart platform that informs you of the most important information without any effort from you is required.

This is an exciting time for provider billing teams.  At DocVocate, our team is passionate about helping provider billing teams.  We’ve spent considerable time thoughtfully building our platform, Appealio, just for you.  New tools are on the way to help!

If you found this helpful and would like to discuss further, please feel free to reach out to us at info@docvocate.com.

Are You Getting the Most Out of Your Credentialing?

Are You Getting the Most Out of Your Credentialing?

Are You Getting the Most Out of Your Credentialing?

Enrollment status can greatly affect the dollar amount payers reimburse, and some specialists are opting to go out of network. We weigh the pros and cons of this trend to explain why it may make sense for select providers.

Did you know that reimbursement is directly tied to credentialing? It’s all in the details, and enrollment status can greatly affect the amount payers reimburse. When enrolling as an in-network provider, payers and providers decide on an agreed-upon rate. However, a physician can decide to forgo a traditional contract with a payer and instead choose to be labeled as “out of network”. Of course, they will still be listed as a provider, albeit without the stated reimbursement rates and payment security that comes with having a contract in place.

If you are wondering why this option is appealing to some physicians, just look at common treatments the average healthcare consumer may be familiar with. Every year, most adults and children visit their local eye specialist for an annual exam. An optometrist performing a routine eye exam will most likely receive optimal reimbursement. This service is covered by insurance in the majority of cases and the reimbursement will be within a standard range. However, if this same patient is then referred to an ophthalmologist for advanced cataract surgery, for example, the odds of insurance covering this procedure are less likely. From the standpoint of the ophthalmologist, his credentialing specifics may not matter too much, since he will be paid regardless and the patient is most likely assuming that they will have a large out-of-pocket cost. When all is said and done, the ophthalmologist is set up to take home more than if he was listed as an in-network option. Looking at it through the eyes of the surgeon, it would not make sense financially to be credentialing with payers the traditional way.

The benefit of being in-network boils down to the contracts that determine what providers will be paid. When a provider works with a payer, an agreed-upon rate is determined. If paperwork is filled out correctly and claims are submitted on time, there will not be too many surprises when the time comes to be reimbursed. A provider will know what to expect from a particular service. This process works best for providers that like the security of having a contract in place. However, these contacts with insurance companies often result in providers being paid less than fair market value. The truth of the matter is that fair market value may often be more than payers are willing to pay.

It’s not uncommon for family doctors, or eye care professionals that deliver routine exams like the example mentioned above, to work in-network because the margins are small.  For highly specialized services, often considered elective and not covered by insurance, the potential for large reimbursement grows significantly. For instance, let’s say a plastic surgeon performs surgery in their own surgical suite. The procedure may cost $14,000. Through payer reimbursement as an in-network provider, the surgeon receives $4,000. However, if the surgeon is considered out-of-network, they have the ability to negotiate rates, meaning much more could potentially be earned. From the patient’s standpoint, it’s not uncommon for a patient to shop around and expect to use an out-of-network provider anyway for these types of highly specialized services.

When it comes to gaining credentials, an out-of-network provider will not have to go the traditional credentialing route. This question arises: Is it smarter for medical professionals to perform their services as in-network or out-of-network providers? The truth is, a lot of doctors do not actually realize they have the ability to negotiate. It all comes down to how they want to pay, and the power lies with the provider.

Credentialing is complicated, and it helps to have the right partner in place to navigate the path to credentials. TriZetto Provider Solutions (TPS) has experienced credentialing experts in place that can help with every aspect of the process. Visit our TPS partner page to learn more and request a demo.


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.