For many providers, medical claim denials are one of the single biggest drains on revenue. When you consider that working just one denial costs about $25, knowing why claims are being denied and how to prevent them in the future isn’t a luxury—it’s a necessity.
Automation and advanced analytics can take much of the burden off your billing team by helping you identify potential denial triggers, adapt to constantly changing payer guidelines, and uncover actionable trends in your claim data.
Waystar’s Denials by the Numbers:
5-10% average denial rate amount physician practices
90% of denials are preventable
76% of providers say denials are their biggest RCM challenge
[ Note: View or download Waystar’s “Defeat Denials with Data” white paper here ]
Waystar, a partner of EZClaim, integrates easily with its medical billing software, creating a seamless exchange of claim, remit, and eligibility information. To learn more about defeating medical claim denials, or to add Waystar as your clearinghouse, visit this page.
ABOUT EZCLAIM: 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.
[ Article and white paper contributed by Waystar ]
With the cost of insurance premiums and deductibles both on the rise, patients have begun taking on greater responsibility for paying for healthcare than ever before. In return, they are becoming more discerning shoppers and expect more from the patient experience that their providers are delivering. One of the biggest steps that have been taken to create a more standardized, consumer-like experience is the introduction of the final price transparency rule from the Centers for Medicare and Medicaid Services.
More than half of consumers have received an unexpected medical bill
Despite the $3.81 trillion that was spent on healthcare in 2019, America’s healthcare paymentssystem has long remained opaque and broken. Patients are frequently faced with unexpected or surprisingly high medical bills, discover too late that a provider they’d been told was in-network was actually out of network, and are forced to wait 60-90 days to receive their medical bills.
Patients are more concerned about billing than the quality of care
In October 2020, Waystar surveyed 1,000 consumers about their experiences with medical bills, and awareness and attitudes towards the upcoming price transparency rule. More than half of respondents have received an unexpected medical bill, meaning that they assumed a service was covered by insurance and it ultimately was not, or the amount they expected to pay out of pocket was different from the bill they received.
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, visitEZClaim’s website,e-mail them, or call them today at 877.650.0904.
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.
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:
1. Pre-appointment 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 ]
ABOUT EZCLAIM: 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.
Today’s healthcare landscape faces truly unprecedented challenges, which means it’s more important to get the most out of your analyticsto develop more informed, strategic decisions. There’s a deep well of data that each revenue cycle feeds into, which if properly analyzed, can help organizations operate at their most efficient and effective. Here are the four stages of data analytics workflows that are key to developing those actionable insights: A “Trigger,” or the point in your revenue cycle that sets up the call for deeper analysis; “Interpretation” of data to determine root causes and identify appropriate next steps; “Intervention” to improve specific metrics; and “Tracking” of said metrics to chart success in achieving desired outcomes.
So, let’s examine what a successful version of each stage looks like:
Trigger: The trigger occurs when you notice something that needs further investigation. With the right analytics tool you can easily access all of your key performance indicators, financial goals and more, providing the visibility you need into your rev cycle. When something looks amiss or needs improving, you can drill down to the level that shows what’s really going on.
Interpretation: Even a wealth of data amounts to nothing without an efficient way to process and communicate key takeaways. You’ll need to equip your team with access to concise reports, smart visualizations and relevant historical data in order to get them to the insights that drive action.
Intervention: Now is the time to take action. Intervention is ultimately tied directly to your ability to drill down into the data underlying problematic areas of your revenue cycle and clearly communicate takeaways with your team. Success at this stage depends on designing a plan based on your best understanding of underlying issues and the most effective way to address them.
Tracking: Your intervention plan is built on KPIs that naturally intertwine with the way you measure success across your revenue cycle. With proper implementation and tracking, running with the analytics cycle can become a simple addition to your everyday workflow. More than delivering on your initial goals, the true power of analytics is the ability to deliver repeat value on your initial investment.
Wrap Up A strong analytics solution does more than deliver a more fully developed picture of your revenue cycle performance. It provides actionable business intelligence, cuts down on time between analysis and action, and lessens the strain on your IT department.
Waystar is a ‘partner’ of EZClaim, and provides analytics for a practice using their medical billing software. For more details about EZClaim’s products and services, visit their website: https://ezclaim.com/
To learn more about how Waystar can help you harness the power of your data, call their main office at 844-4WAYSTAR, or call sales at 844-6WAYSTAR.
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.
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.
Provider Analysis: 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.
Maximizing Reimbursement: 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.
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