As competition in the healthcare industry continues to heat up, providers and billers must look to new options to provide seamless and flexible payment options to retain customers and attract new ones.
Providing a variety of convenient payment options is more important than ever
Patients are frustrated by their healthcare payment options. While they understand the importance of paying their bills, they also want to be able to pay them in a way that is convenient. Many patients would rather pay their bills by credit card rather than cash or check, but they do not always have this option.
Patients have adopted a consumer mindset. From their perspective healthcare transactions should be no different from other transactions. They are more reluctant than ever to put a check in the mail and cross their fingers. In a world of easy online payments and tap-to-pay convenience, healthcare providers need to recognize that the patient financial experience is just as important as the patient care experience.
Most importantly, providing these payment options are not just about giving patients more convenience, but about the bottom line. Embracing new functionality like card-on-file recurring billing and SMS text message payment reminders saves your staff time and increases payment rates.
“We sent out the first SMS payment requests last week, and within several hours had generated 9 payments for a total of over $2,400 back from the patients! The provider is thrilled.”
As the healthcare industry continues to become more competitive, it becomes more critical than ever to create efficiencies wherever possible.
Patient payment data security must be a top priority
In 2016, healthcare organizations suffered a record-breaking number of data breaches. These breaches are not just affecting the health of patients and the financial bottom line of providers – they are also affecting their reputation.
A survey conducted by Ponemon Institute in 2017 revealed that healthcare organizations lost an average of $2.1 million per breach and nearly a third reported losing between $1 million and $10 million per breach. In addition to these costs, there are also significant reputational consequences for healthcare organizations that suffer a data breach. More than half (52%) said they would avoid using a provider following a data breach.
Consumers are concerned about safeguarding their medical information when paying bills; 47% have significant concerns regarding the security of making payments for both medical bills and health plan premiums. They want to take advantage of the consumer protection guarantees that their credit card company offers and a PCI compliant payment processing like EZClaimPay.
Finding the right payment processing partner
Healthcare is more complex than many other industries — a tangle of relationships between patients, healthcare providers, insurers, and unique regulatory requirements such as HIPAA. In this context, there are many providers find that their payment and billing systems do not work well together. Because of these challenges, medical billers and healthcare providers stand to benefit by working closely with their payment processors.
EZClaim set out to build a payment processor from the ground up that addresses these concerns. EZClaimPay helps billers and providers save time and money with functionality like card-on-file recurring billing, ability to offset processing costs with the platform fee functionality, and automatic reconciliation. Plus, increase payment rates with text message reminders and convenient payment portal. Most importantly, because we serve healthcare providers exclusively, we have ensured compliant, industry standard security including PCI compliance.
Streamlining and optimizing payment processing expedites the patient payment process while increasing back-office efficiencies. Healthcare providers that offer seamless, secure, and flexible billing and payment options will retain more customers and continue to attract new ones.
EZClaim is a leading medical billing, scheduling, and payment software provider that combines a best-in-class product with exceptional service and support. For more information, schedule a consultation today, email our experts, or call at 877.650.0904.
The revenue cycle is a crucial component of a medical practice. Revenue Cycle Management (RCM) is the process of managing patient accounts, interacting with payers, processing claims, and collecting payments related to health care services. As the industry becomes more competitive and physicians are expected to perform more administrative tasks on their own, RCM has become even more important for healthcare providers today than ever before. Unfortunately, many practices still struggle with managing their RCM processes in an efficient manner that allows them to focus on what matters most: patient care. Below is a list of common mistakes made by healthcare providers when it comes to RCM.
Below is an overview of the seven key components of RCM and ways to avoid some of the most common mistakes.
Insurance Verification and Authorization
Insurance verification and authorization is a critical step in the revenue cycle process. If this step fails, all other steps must be repeated. This can result in delays, rework, denials of claims and even patient non-compliance.
- Verify that the patient is covered by their insurance plan and will not be responsible for additional costs related to their treatment or procedure (co-pay and deductibles).
- Verify that your provider is in network for each specific procedure with their chosen health plan/policy before completing any work on behalf of the patient.
- Ensure that all documentation supports your claim(s), including diagnosis codes and clinical notes from EMRs or doctors’ offices detailing what was performed during each visit. These details should align with those found on physical charts signed by both patients and providers alike.
- Verify eligibility rules as defined by health plans: has a deductible been met? Is there a copay amount due before benefits kick in? In some cases it may be necessary to contact members directly via phone or email asking them these questions so they know exactly how much they owe out-of-pocket. Our partner TriZetto Provider Solutions offers integrated eligibility verification. Automating this due diligence on the front end ensures that you are not left with the cost of having a biller redo this work, or worse, writing of claims.
Patient Registration and Copay Collection
Patient registration and copay collection are important first steps to ensure that your revenue cycle is functioning properly. Patient service, claims submission, remittance processing, and back-end patient collections are all vital components of the revenue cycle management process.
Without these steps in place, you will not be able to complete the full revenue cycle management process.
Service Coding and Charges
The service coding process identifies the type of service or procedure that was performed by your staff. Accurately documenting and coding charges allow you to:
- Assign appropriate codes for reimbursements from government programs, insurance companies and self-pay patients.
- Determine the level of reimbursement for each code
- Avoid fraud and abuse
Billing and Collections
It is critical to collect payments on time, in full and accurately. If you do so consistently, it will be easier to predict future cash flow needs and improve your ability to manage the revenue cycle.
Timely billing is critical because it allows the practice to collect their fees before they become delinquent. Delinquent accounts must be reported to credit agencies which can negatively impact a patient’s ability and willingness to pay for other services at your facility in the future. Late fees should also be considered for patients who are more than 60 days late paying their bill – this can help generate additional revenue by encouraging prompt payment from patients who may otherwise have ignored their bills altogether.
Accuracy is key when collecting payments because inaccurate claims may result in denied reimbursement by Medicare or third-party payers’ due out-of-pocket expenses for patients who were mistakenly overcharged by providers.
Consistency means that providers need regular updates on where each account stands within its cycle; this helps ensure that both patient satisfaction levels remain high and that everyone receives timely access. Efficiency refers not only to how quickly accounts move through management but also how quickly they get paid so providers know exactly how much money they’ll have coming in each month before making subsequent budgeting decisions.
EZClaim provides great tools to help ensure your collections are timely, accurate, and consistent. EZClaim allows you to keep a credit card on file. With approval to charge up to a specified amount, you can make it convenient for your patients and ensure payments are timelier than ever. EZClaimPay also offers email and SMS text message-based reminders, which have proven effective in increasing payment rates.
Denial management is the process of managing patient denials. Denials can be caused by a variety of reasons, including incorrect CPT codes, missing information, or provider errors. Therefore, it’s important to have ready-to-go processes for handling them and getting paid as soon as possible.
When you receive a denial from an insurance company, there are several things you should do immediately:
- Double-check that all your claims are accurate and complete before submitting them for payment. If there is any ambiguity on the part of the patient or their healthcare provider, this will increase the likelihood that your claim will be denied due to lack of clarity.
- Request that more specific details regarding the denial be provided. This allows better preparation when submitting future claims related to this patient’s care and ensures there aren’t additional denials for similar reasons.
The revenue cycle is a crucial component of any medical practice. It’s also one of the most challenging aspects of running a practice, especially in today’s increasingly complex environment. This article has highlighted some common mistakes that can be made when managing your revenue cycle and how to avoid them.
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.
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.
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 ]
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]