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.
Apr 12, 2022 | Partner, TriZetto Provider Solutions
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.
Feb 10, 2022 | Partner, TriZetto Provider Solutions
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 Solutions’ designated 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.
Feb 9, 2022 | DocVocate, Partner
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.
Jan 15, 2022 | EZClaim
As we move into the new year, we wanted to take a moment to share the most popular articles of 2021. We’ve ranked them below so that you can be sure that you haven’t missed out on any resources that EZClaim clients have found useful in the past year.
Here are the most popular blog posts of 2021:
This interview was by far and away the most popular blog post over the past year. Jennifer and Maura provide some great insight and best practices, including their “investigative” approach to medical billing and the problem-solving skills that are necessary. Here is a summary of that article:
Are you working in the medical billing industry as a biller or an owner of a billing company? If so, the key medical billing insights and best practices that came out of our interview with Maura Jansen (VP of Operations) and Jennifer Withington (Director of Revenue) at Missing Piece Billing & Consulting Solutions will be very valuable for you to consider.
Jennifer, an expert in understanding the problem-solving techniques and the investigative nature of medical billing, offers insights that both educate and inspire. Maura, an executive member of the billing community, also added an important perspective about EZClaim’s medical billing software. The following are some highlights from our interview.
Getting patient billing information quickly can be a big pain point, so it makes sense that this article was among the most read of the year. We walked through some tips and ticks for saving time including the EZClaim eligibility feature:
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.
In this interview with a medical billing expert and co-owner of Elite Billing Resolutions, Vicky Greenwood, we talk about dealing with the challenges in owning a billing company, some important skills that every medical biller needs, and the value of choosing the right medical billing software. In our time speaking with Vicky, we focused on topics that will aid, contribute, and help grow the skills of the medical billing community. We at EZClaim believe in highlighting the best practices in the industry and sharing those with the larger community. We encourage you to consider these insights, and then let us know what topics you would like to learn more about.
Double data entry is frustrating. Luckily there is a better way—integrating your EHR with EZClaim.
Are you or your staff having to enter every patient into your EHR program and then again into EZClaim? There is an easier way! Integrating your programs will put an end to duplicate data entry, saving your practice time and money!
So, what exactly is an interface and how does it work? An interface is a way for two programs to share information. For EZClaim clients, the interface can be set up to share data from your EHR program to EZClaim. Your EHR can give you specifics on how to send the data to EZClaim.
Minimizing and preventing claim denials is a challenge that providers are increasingly running up against. We put together four strategies to address this growing problem:
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.
There you have it, the most popular posts on the EZClaim blog in 2021. We look forward to keeping you up to date on everything medical billing in the new year!
