It is estimated that 30-50% of denied claims occur on the front end during the patient access process, namely during registration, authorization and eligibility. Unfortunately, manual patient intake processes contribute to these denials, and ultimately, the bottom line, staff productivity and the patient experience take the hit.
Banner Health chose to automate its patient access processes with eCare NEXT from Experian Health. The solution, which integrates directly with Banner Health’s acute and ambulatory electronic health records (EHRs), automates the organization’s preregistration workflow, including medical necessity and financial clearance. This improves registration accuracy, provides more accurate patient estimates and reduces the number of denials on the front end.
Banner Health has benefited by incorporating a mix of Experian Health products that integrate directly and collaborate with other technologies and workflows already in place:
Decrease in eligibility errors. With eCare NEXT, initial denials due to eligibility errors have been reduced by $30M in the first quarter alone since going live with Experian Health.
Significant cost savings. With more accurate estimates, Banner Health has seen significant cost savings on the front end from more efficient coverage discovery. The system is consistently finding 30+% unique or new coverage in the patient access workflow.
Improved staff engagement and satisfaction. Automation has greatly reduced manual inputs, enabling staff to focus more on the patient rather than systems and logins required for patient intake.
Our partnership with Experian Health helps Banner Health’s revenue cycle team deliver on its mission of “getting it right, at the right time, every time.” — Becky Peters, Executive Director of Patient Access Services, Banner Health
Want to learn more about Banner Health’s success in finding unidentified coverage earlier in the revenue cycle? Sign up for the January 21 webinar below, where attendees will gain insight into the organization’s proven workflow and processes.
There is no question that providers’ bottom line has been hit hard this year, and a new surge in COVID-19 is bound to threaten hospital finances once again.
As healthcare providers look to supercharge their payment velocity during these uncertain times, it’s worth taking a step back to examine the revenue cycle management process as a whole: what it is, how it works, and the clear actions providers can take to improve the process overall.
Below is an overview of healthcare revenue cycle management and how specifically providers can improve their bottom line now and after the pandemic subsides.
What is revenue cycle management?
Any business, regardless of industry, needs to develop successful processes and strategies for remaining financially healthy. For hospitals and health systems, that process is revenue cycle management. To run a successful healthcare organization, providers must employ and manage accurate and efficient billing processes. Without it, these organizations will likely have to close their doors and will, as a result, no longer be able to provide quality care for their patient population.
How revenue cycle management works in healthcare
To put it simply, in order to generate revenue for their organization, providers need to collect payments for services rendered. The process of doing this, however, isn’t always as straightforward and simple as it seems.
Think of healthcare revenue cycle management like a journey. It starts when a patient schedules an appointment and ends when all patient payments for medical service(s) received have been collected. As we move through the journey, providers have a lot to manage, starting first with front-end intake process, moving all the way through the back-office operations to ensure payment is ultimately secured.
Phases of the revenue cycle management life cycle
The revenue cycle management life cycle spans several phases:
Schedule visit and secure estimate. To kickstart the process, a patient will book an appointment with a provider or specialist and administrative staff will handle insurance eligibility verification and ultimately establish a patient account for that organization. This is also an opportunity for providers to offer price transparency and provide an estimate for services to be rendered.
Registration and check-in. An early and vital step for optimizing the entire revenue cycle management process, this is where providers capture details like medical history, insurance coverage and other patient demographics. Ensuring correct patient information on the front end reduces the errors that cause rework in the back office.
Ensure care is authorized by the payer. Still on the front end, this is where provider staff checks whether prior authorization is required for a particular procedure or service. Not securing authorization in advance of service can lead to costly denials, rework, operational inefficiencies, and a poor patient experience.
Receive treatment and discharge. Once the patient is discharged, the services provided will be translated into billable charges and a medical billing code will be assigned to the claim. It is crucial to the revenue cycle that these claims be accurately coded, as the re-work for incorrect codes and subsequent claim rejections can be costly and a drain for productivity.
Medical claims submitted. The claim must then be submitted to the payer. Submitting accurate and timely claims maximizes the revenue collected and prevents delays in reimbursement. Rejected claims directly affect an organization’s revenue cycle, making it all the more important to get the claim right before it makes its way to the payer. Even if a claim is denied, is important it be resubmitted as quick as possible.
Patient payments and collections. Once insurance reviews the claim and provides their reimbursement, patients are presented with their out-of-pocket costs for services rendered. On-time payments made in full are preferable for a healthy revenue cycle, but that isn’t always feasible for patients, especially now given the current environment with COVID-19. This is where quality collections practices can really help to optimize patient payments and reduce bad debt.
Challenges in revenue cycle management
Any process with this number of touch points is bound to come with challenges, but two major challenges seem to stand out: claims and collections.
Navigating healthcare claims is complex and costly. Providers and facilities often get stuck in a cycle of inaccurate claim submissions, denials, corrections and rebilling that delays reimbursement and negatively impacts financial performance.
A lot of denials can be traced back to errors within the claim submission: improper coding, issues with insurance eligibility, missing or inaccurate patient information, or duplicate claim submission. Errors like this on the front-end are a major cause of the headaches experienced by providers further down the line.
After claims are submitted, provider staff will monitor and keep track of claim status. Surprisingly, many still use a manual process not only for this, but for managing any claims that are ultimately denied. Without any kind of automation, this is a drain on productivity, time and resources and it becomes more difficult for providers to respond to denied, pending or returned claims in a timely manner for reimbursement.
Another prominent challenge in the revenue cycle is collections, notably collecting from patients before or at the point of service. Providers would prefer to collect from patients prior to them leaving the office, but it’s not always possible, and for a few reasons.
Patients are increasingly unable to pay their medical bills, more are presenting as self-pay (maybe now more than ever during the pandemic), and some may not be aware of subsequent coverage or that they qualify for charity assistance, all which directly impact providers’ abilities to collect. A lack of price transparency for services can make it even more difficult for patients to prepare financially.
Benefits of revenue cycle management
Despite its challenges, when done right, there are many benefits of revenue cycle management in healthcare.
Effective revenue cycle management not only improves the patient experience but improves staff satisfaction as well. Automating the process (billing, coding, claims management, etc.) reduces a lot of the associated administrative burden, which allows providers to focus on the delivery of quality care.
An optimized revenue cycle will also lower the rate of denials. As errors and redundancies are addressed and prevented on the front end, fewer claims will be denied.
Maybe one of the most obvious benefits of a healthy revenue cycle is maximized collections and revenue, and faster collection processes, especially when the process is automized. The entire collections process can be expedited, lowering administrative burden while also improving accuracy.
How to improve your revenue cycle management
We recommend providers take a holistic approach to improving revenue cycle management, focusing largely on automating the process and within the following four areas:
Automate access Patient access is the starting point for the entire revenue cycle process. Ensuring correct patient information on the front end reduces the errors that cause rework in the back office. patient access.
With an automated, data-driven workflow, providers can reduce the errors that lead to claim denials while simultaneously improving access to care for patients through capabilities like online scheduling. Access is further improved by reducing the friction around patient billing by leveraging real-time eligibility verification to deliver accurate patient estimates at registration.
Increase collections There is a definitely a delicate balance between ensuring that debts are collected and fostering a positive patient financial experience. It is imperative providers find a way to maximize patient collections while also increasing patient satisfaction. Patient access staff must be the patient’s advocate while also improving the organization’s ability to collect from the patient and payer.
By leveraging a data-driven approach, staff can verify patient identity and insurance coverage as well as provide an accurate estimate of payment responsibility ahead of service. Staff even can review data to assess ability to pay and evaluate various payment plan and/or financial assistance options.
The further upstream the revenue cycle can be managed the more effective the process will be to ensure the patients are informed prior to service, so they can make their portion of their payment responsibilities as early as possible to accelerate the cash collections for providers and to reduce the need to put significant effort into late stage collections.
Streamline claims Providers can improve financial performance with automated, clean and data-driven medical claims management.
By integrating claims management software with customized edits into the workflow system, providers can thoroughly review every line of every encounter and verify that each claim is coded properly and contains the correct information before the claim is invoiced and submitted for reimbursement.
Encounters can be processed in real time with automatic alerts for incorrect codes or other potential issues before the claims submission. Responses include a detailed explanation of why a claim was flagged, so any necessary modifications can be made prior to submission.
Increase reimbursement Healthcare organizations that don’t stay current on payer policy and procedure changes risk payment delays and lost revenue. It can also be difficult for providers to verify the accuracy of payment received from third-party payers.
With automated access to the right data, providers can be reimbursed more accurately and quickly, while also strengthening their relationships with payers.
Providers can avoid payment delays and lost revenue with automated payer policy and procedure change notifications. Solutions that continuously audit payer contract performance can assure that collections align with negotiated terms.
The key for successful revenue cycle management
Technology, specifically data and automation, is key to the success of the healthcare revenue cycle. Automation ensures problems don’t continue to effect productivity, and data can be matched precisely to predict, model and optimize financial results. Both can also be used to highlight a patient’s financial situation, as well as their propensity to pay, allowing providers to optimize collection strategies from the start and get patients on the right programs.
Explore Experian Health’s revenue cycle management solutions.
Claims denials put a big dent into the budgets of healthcare providers – something many organizations can’t afford today given the current pandemic. In an environment where everyone must do more with less, reducing claim denials could release vital revenue and staff time to create breathing space for quality improvement.
The good news? About 90% of claims denials are preventable when healthcare providers automate revenue cycle functions. In fact, providers could gain an estimated $9.5 billion by automating the claims management processes.
Here are 5 ways for providers to proactively reduce claim denials.
Healthcare providers should shift from reactive to proactive claim denial management, looking at the whole RCM process.
On the front-end, that includes streamlining the patient registration process. By achieving near-perfect levels of accuracy on the front-end, providers can prevent costly claims denials and unnecessary re-work on the back-end of the revenue cycle.
In a trial last year, a federal judge found that a UnitedHealth subsidiary had illegally denied mental health and substance use disorder claims. The same judge has now ordered the payer to reprocess all the claims and reform its guidelines.
With COVID-19 leading to postponed and cancelled
medical appointments, more consumers are turning to “contactless care”. Recent
figures suggest telehealth adoption has shot up from just 11% in 2019
to 46% over the course of the pandemic, and some providers
are seeing up to 175
times the number of telehealth patients than pre-COVID. As
they grapple with the surge in patient volumes alongside regulatory change,
many are playing catch-up.
For patients, rushed implementation means the
telehealth experience can fall short of expectations. Compared to the easy
one-click services available with online retail and finance platforms,
telehealth can feel clunky and frustrating. Technical issues, not knowing how
to prepare for appointments, and a lack of awareness of available services can
all taint the consumer experience.
Providers looking to launch (or re-launch) a patient-friendly
telehealth service ahead of a possible second wave should aim to check off
these four considerations before rolling it out.
1. Prioritize easy online scheduling for virtual care
Allowing patients to book telehealth appointments when it suits them will help to reduce no-shows and minimize delays. A telehealth platform that integrates with physician calendars and other patient management and record management systems will keep things running smoothly at the operational level, while creating a convenient and secure way for patients to schedule care.
Health System implemented Patient
Schedule, more than 50% of patients chose to book their appointments out
of normal working hours. Sam Martin, digital developer and web specialist at
not allowing your patients to schedule online, you’re behind the times. You can
only benefit from it. We’re seeing the number of online bookings continue to
grow every month, confirming that this solution is working for patients.”
2. Include quick and reliable coverage checks
pandemic and resulting unemployment putting both provider and patient cashflow
under strain, any available commercial or government coverage must be
should run automated coverage checks to find any missing coverage and select
the right financial pathway for each patient as soon as possible. Not only will
this create a more compassionate patient financial experience, it’ll allow the
collections team to focus their attention on the right accounts and minimize
the risk of write-offs.
Discovery screens for eligibility
through Medicare, Medicaid or commercial plans, without any collections agency
With this tool, Essentia Health were able to find
coverage for 16,990 accounts that were assumed to be self-pay or uninsured. Kathryn
Wrazidlo, Patient Access Director, says:
helped patients because we’re actually billing their insurance versus billing
them for self-pay. It’s helping staff because they’re billing the insurance
company much quicker. There’s less rework.”
3. Get telehealth claims right first time
the pandemic may cost hospitals an estimated $200 billion
between March and June 2020, there’s no room for the added financial burden of
claim denials. But as telemedicine expands, so does its regulatory framework. Providers
must keep track of changing payer updates and coding rules so that claims are
submitted right first time.
management tool can help providers analyze claims with greater confidence and
spot any errors well in advance of submission. Telehealth alerts can be
included as customized edits, to confirm whether the patient’s current plan
includes virtual care. To help providers manage this process, Experian Health
is offering free access to telehealth payer policy alerts through our COVID-19
4. Protect patient data
As with any
part of the digital patient experience, a multi-layered approach to protecting
sensitive information is a must. Ideally, this will include two-factor patient
identity authentication, device recognition and out-of-wallet checks whenever a
log-in attempt looks suspicious.
Automating this process with a tool such as Precise ID allows providers to integrate multiple data points to check that a
patient is who they say they are, in a way that’s HIPAA-compliant. This makes
it harder for thieves to access patient data, without burdening the patient
with extra checks as they manage their information.
Retaining patient volume and rebuilding revenue through
“contactless” care won’t be possible unless the entire telehealth journey is as
seamless as possible. From scheduling to payment, Experian Health can help you create
a virtual patient experience that’s convenient, secure and reliable. Contact us to find out