4 Quick Tips for Getting COVID-19 Claims Paid Promptly

4 Quick Tips for Getting COVID-19 Claims Paid Promptly
Lillian Phelps, Sr. Director of Product Management, Availity

As the COVID-19 pandemic has gripped the world, many providers have adopted an all-hands-on-deck approach and mentality for treating COVID-19 patients, stretching their resources to the breaking point. 

We have heard about the frontline heroes who have sacrificed their own health and safety to treat patients and, in less-fortunate scenarios, comfort patients in their last moments as they were quarantined from loved ones. 

What has been less recognized is the work and sacrifice put forth by providers’ back-office staff. Many back-office workers have had to transform their operational practices after shifting to “work-from-home” mode to avoid potential exposure and minimize traffic to hospitals and physicians’ offices. 

In addition to working in new environments, some of these back-office administrators who help process claims, receive reimbursements, check eligibility and manage denials are also seeing a higher volume of claims that are more complicated in nature due to the severity and complexity of managing COVID-19 symptoms in patients. Others are working with bare-bones staff as elective procedure volumes have decreased. 

The biggest challenges with COVID-19 claims
While many aspects of the pandemic are beyond providers’ control, proper coding of COVID-19 claims is one area they can focus on to help ensure efficient operations and revenues. Of course, that is easier said than done. The following are just a few challenges providers have been facing with COVID-19 claims.

Increased complexity: Due to the complexity of COVID-19 cases, which affect many elderly patients and those patients with chronic conditions and comorbidities, associated claims often take longer to code, file and process compared to more straightforward cases. More complex COVID-19 cases lead to longer hospital stays, which can create delays in submitting claims, resulting in delays in receiving reimbursements.

Continued shift to electronic transactions: While many hospitals and provider groups have shifted to submitting claims electronically, many processes, including prior-authorizations, eligibility and estimation requests and grievances, and appeals, rely heavily on manual intervention. These processes frequently require access to faxed or paper documents. Administrative staff members have had to quickly learn new systems and processes.

Difficulties with reimbursement for the uninsured: Through the Coronavirus Aid, Relief, and Economic Security Act (also known as the CARES Act) and other legislation, the federal government has appropriated funding earmarked for providers that deliver COVID-19 testing and treatment to the uninsured. While this was certainly a welcome gesture at a time when many have lost their health insurance due to unemployment, the support has come with some administrative strings attached that lead to challenges for providers. 

For example, before submitting a claim, providers must show they have gone through an attestation process and document their efforts to find other medical coverage for the patient. Then providers essentially have just one shot at submitting a clean claim, as there is no appeals process for denials deemed inappropriate or unjustified. In cases of denials, providers themselves have little recourse for obtaining reimbursement and end up with a loss in revenue and increased costs. Although the efforts to help uninsured patients with COVID-19 testing and treatment are well-intentioned, providers must follow specific steps to realize the benefits.

Processing COVID-19 claims more efficiently
It has become clear that COVID-19 claims, though in many ways similar to traditional claims, have unique impediments that create difficulties for hospital and provider administrators. We have observed this in our own data. When comparing COVID-19 claims to non-COVID-19 claims, the COVID-19 claims have demonstrated a greater error rate (9-12% compared with 5-7%) and a longer time to submit (45 days compared to 30 days).

Despite these challenges, providers can implement the following steps to manage the workload, process COVID-19 claims efficiently, and work within the constraints of their new “work-from-home” offices.

1. Leverage technology that identifies errors and provides upfront edits to all COVID-19 claims. Automated revenue cycle solutions should contain updated functionality to properly review claims and flag potential issues prior to the claim being submitted to a payer.

2. Move coverage discovery to the front end of the billing process and ensure it is performed for all patients. There are many solutions that will search for insurance coverage across both commercial and government payers. When identified, the payer information can be reviewed and added to a patient’s billing information.

3. Review analytics within the revenue cycle management system to identify COVID-19 claims. Analyze these claims by payer, claim amount, and number and severity of services rendered. Scrubbing and editing claims in advance will ensure accuracy while also highlighting anomalies to review and fix prior to submitting the claim.

4. Constantly review claims for inpatient stays to ensure that all charges are recorded and all medical records are updated and attached. Getting all documentation ready and prepared in advance will save time on the backend.

Though we all hope that the pandemic winds down and we soon return to some sense of normalcy, it takes more than hope for providers to get their COVID-19 claims reimbursed accurately and quickly. Following the tips above will help keep administrative processes running smoothly and alleviate burdens that will inevitably occur once patients are treated and the billing cycle continues. 


About Lillian Phelps

Lillian Phelps is the senior director of product management for Availity, the nation’s largest health information network.


Gleaning Insights for COVID-19: Why Claims and Clinical Data Matter

Navigating Healthcare’s Uncertain Future: Three Data-Driven Approaches for Payers
Emad Rizk, M.D., President, CEO & Chairman of the Board, Cotiviti

As 170 research teams race to develop a vaccine for COVID-19, some that are in late-stage approvals have seen recent progress, but it is still not yet clear when a vaccine will become widely available. Until then, healthcare organizations continue to rely heavily on data analytics to try to improve COVID-19 outcomes and public health.

Since the novel coronavirus became widespread in the U.S., healthcare data scientists have leveraged clinical and claims data to pinpoint which underlying conditions put patients at higher risk of complications from COVID-19. Health systems are mining clinical data to predict surges in COVID-19 cases and looking at key factors—including increases in hospital website traffic, such as searches for emergency department (ED) wait times and physician page clicks—to understand how COVID-19 is ramping up locally in real-time. Meanwhile, risk-based modeling has helped health plans address social determinants of health that could impede recovery.

Now, providers and health plans are refining their approach. The more they learn, the greater the benefit to public health and long-term outcomes. Three evolving use cases for using claims and clinical data to combat COVID-19 stand out.

Reduce disparities in care. Early in the pandemic, lack of complete information around patient demographics prevented the identification of members in communities that were most vulnerable to COVID-19 infection. The impact: severe differences in mortality rates. In Chicago, the rate of mortality among Black residents was alarmingly high—70% of COVID-19 deaths—even though these residents comprise just 29% of the city’s population. Meanwhile, Spanish-speaking residents account for 18.3% of the nation’s population, yet comprise 34.3% of coronavirus cases.

One of the reasons demographic data was often missing from COVID-19 lab tests is that laboratory and hospital staff were too overwhelmed with cases to have time to input all of a patient’s non-clinical information. Today, data scientists are working to fill in the gaps using clinical history and medical claims. With these analyses, healthcare organizations are closing gaps in care, such as by expanding access to COVID-19 testing for the nation’s most vulnerable populations and increasing access to professional interpreters to more effectively gather key patient details. They are also addressing social determinants of health that heighten risks, such as food insecurity and lack of access to prescription medications.

Alleviate reliance on spotty testing. Not everyone who contracts COVID-19 has a healthcare encounter. For instance, if one member of the household tests positive for the coronavirus, other members may decide not to undergo testing if their symptoms are mild. These are instances where analyses of clinical and claims information already in the system—both emerging and historical data—can help spot unconfirmed cases of COVID-19. Such analyses give public health officials the information they need to contact, test,s and quarantine individuals that have contracted the virus, helping to limit the spread of the disease.

On a wider scale, data analysis can also provide early warning surveillance of potential COVID-19 cases, strengthening the pandemic response. For example, by observing increases in medical claims for telemedicine, rapid flu tests, and chest X-rays, data scientists can detect patterns in claims that suggest a COVID-19 outbreak is likely to occur. From there, they can forecast demand for hospital care up to 10 days in advance, ensuring that facilities have sufficient staff, supplies, and beds available to meet their community’s needs. Similarly, disruptions to seasonal flu trends, which remain fairly consistent within a region year over year, could alert public health officials to a potential COVID-19 outbreak.

Avoid preventable deaths. Information regarding patients’ underlying medical conditions can be hard to come by during a public health crisis as overwhelming and widespread as the current pandemic. In fact, just 5.8% of medical records for patients hospitalized with COVID-19 in Q1 2020 had data available related to their underlying health conditions and other risk factors. Today, it is known that certain chronic conditions raise the patient’s risk for severe complications from COVID-19—and that list of conditions is growing. The insight gained from these analyses not only informs how healthcare providers treat an individual’s illness, but also gives those with chronic disease the ability to make informed decisions based on their risk level for infection.

Moreover, the availability of actionable, real-time intelligence to improve health can set the stage for increased care collaboration. During COVID-19, healthcare providers across geographies are sharing their knowledge, especially regarding treatment protocols. Such learnings include the value of using high-flow nasal oxygen in treating severe cases of COVID-19. Early results show that this technique has a positive impact on patients with mild to moderate respiratory failure. It also reduces intubation rates and improves clinical prognosis for patients with acute respiratory failure. By sharing data-driven insights, organizations can work together to improve COVID-19 outcomes and reduce avoidable deaths.

Improving Outcomes and Reducing Risk

Clinical and claims data analysis helps healthcare organizations respond proactively to COVID-19. With the race toward a COVID-19 vaccine well underway, these analyses will help identify which populations should receive the vaccine first, assess reactions to the vaccine by demographic group and spot trends that could affect vaccination protocols. They also give healthcare organizations up-to-date contact information to engage patients, which will be critical to clinical efficacy if a second dose of the vaccine must be administered. In 2020 and beyond, continued focus on clinical and claims data analysis will be key to facilitating a robust response that enhances outcomes and saves lives. 


About Emad Rizk, M.D.

Emad Rizk, M.D., is President and CEO of Cotiviti and brings a 30-year, well-documented track record of delivering improved quality and financial performance to healthcare organizations through forward-thinking leadership, business acumen, and clinical expertise.

Hospital Sustainability Demands that Revenue Integrity Move Front and Center

Hospital Sustainability Demands that Revenue Integrity Move Front and Center
Vasilios Nassiopoulos, VP of Platform Strategy and Innovation, Hayes

Razor-thin operational margins coupled with substantial and ongoing losses related to COVID-19 are culminating in a perfect storm of bottom-line issues for U.S. hospitals and health systems. A study commissioned by the American Hospital Association (AHA) found that the median hospital margin overall was just 3.5% pre-pandemic, and projected margins will stay in the red for at least half of the nation’s hospitals for the remainder of 2020. 

The reality is that an increase in COVID-19 cases will not overcome the pandemic’s devasting financial impact. An internal analysis found that, in the first half of 2020, client organizations documented more than 1.2 million COVID-19 related cases. At least one study suggests that $2,500 will be lost per case–despite a 20% Medicare payment increase. And notably, a positive test result is now required for the increased inpatient payment.

The healthcare industry must face its own “new normal” as the current path is unsustainable, and the future stability of hospitals in communities across the nations is uncertain. If financial leaders do not act now to implement systems and embrace sound revenue integrity practices, they will face unavoidable revenue cycle bottlenecks and limit their ability to capitalize on all appropriate reimbursement opportunities. 

The COVID-19 Effect: A Bird’s Eye View

The financial impact of COVID-19 is far-reaching, impacting multiple angles of operations from supply chain costs to lost billing opportunities and compliance issues. Findings from a Physician’s Foundation report released in August suggest that U.S. healthcare spending dropped by 18% during the first quarter of 2020, the steepest decline since 1959.

Already vulnerable 2020 Q1 budgets were met with substantial losses when elective procedures—a sizeable part of income for most health systems—were halted for more than a month in many cases. Many hospitals continue to lose notable revenue associated with emergency care and ancillary testing as patients choose to avoid public settings amid ongoing public safety efforts. 

Outpatient visits also dropped a whopping 60% in the wake of the pandemic. While a recent Harvard report suggests that numbers are back on track, the reality is that a resurgence of cases could make consumers wary of both doctor visits and elective procedures again.

In addition, the supply chain quickly became a cost risk for health systems by Q2 2020 as the ability to acquire drugs and medical supplies came at a premium. Meeting cost-containment goals flew out the window as did the ability to create value in purchasing power.

Further exacerbating the situation is an expected increase in denials as healthcare organizations navigate a fluid regulatory environment and learn how to interpret new guidance around coding and billing for COVID-19 related care. For example, while telehealth has proved a game-changer for care continuity across the U.S., reimbursement for these visits remains largely untested. History confirms that in times of rapid change, billing errors increase—and so do claims denials.

While there is little that can be done to minimize the impact of revenue losses and supply chain challenges, healthcare organizations can take proactive steps to identify all revenue opportunities and minimize compliance issues that will undoubtedly surface when auditors come knocking to ensure the appropriate use of COVID-19 stimulus dollars. 

Holistically Addressing Revenue

Getting ahead of the current and evolving revenue storm will require healthcare organizations to elevate revenue integrity strategies. Hospitals and health systems should take four steps to get their billing and compliance house in order by addressing:

1. People: Build a cross-functional steering committee that will drive revenue integrity goals through better collaboration between billing and compliance teams.

2. Processes: Strategies that combine the strengths of both retrospective and prospective auditing will identify the root cause of errors and educate stakeholders to ensure clean, timely filed claims from the start. 

3. Metrics: Best practice key performance indexes are available and should be used. Clean claim submission, denial rate, bad debt reduction and days in AR are a few to consider.

4. Technology: The role of emerging technologies that use artificial intelligence cannot be understated. Their ability to speed identification of risks, perform targeted audits, identify and address root causes and most importantly, monitor the impact of process improvements is changing current dynamics. For one large pediatric health system in the Southwest, technology-enabled coding and compliance processes resulted in $230 million in reduced COVID-related denials and a financial impact of $2.3 million. 

Current manual processes used by many healthcare organizations to assess denials and manage revenue cycle will not provide the transparency needed to both get ahead of problems and identify areas for process improvement and corrective action in today’s complex environment. 

About Vasilios Nassiopoulos

Vasilios Nassiopoulosis the Vice President of Platform Strategy and Innovation at Hayes, a healthcare technology provider that partners with the nation’s premier healthcare organizations to improve revenue, mitigate risk and streamline operations to succeed in an evolving healthcare landscape. Vasilios has over 25 years of healthcare experience with extensive knowledge of EHR systems and PMS software from Epic, Cerner, GE Centricity and Meditech. Prior to joining Hayes, Vasilios served Associate Principal at The Chartis Group. 

HealthEdge Software Acquires Payment Integrity Solution The Burgess Group

HealthEdge Software Acquires Payment Integrity Solution The Burgess Group

What You Should Know:

– HealthEdge Software announces the acquisition of The Burgess
Group, LLC (“Burgess”), an innovative payment integrity software company
focused on improving healthcare payment operations for an undisclosed sum.

– The strategic acquisition will boost Health Edge’s position in
the payment integrity market and extends best-in-class claims processing to
include software-driven payment integrity

– Burgess’ product, Burgess
Source®, is the first solution to natively bring together claim payment
automation with business intelligence and enables a unified approach to ensure
payment accuracy. 


HealthEdge Software, Inc.® (“HealthEdge”), a provider of the industry’s leading integrated financial, administrative and clinical platform for health insurers, today announced the acquisition of The Burgess Group, LLC (“Burgess”), an Alexandria, VA-based payment integrity software company focused on improving healthcare payment operations through technology. Financial details of the acquisition were not disclosed. TripleTree, LLC served as financial advisor and Debevoise & Plimpton LLP was legal advisor to HealthEdge and Blackstone. Seabrook Partners, LLC served as financial advisor and Vedder Price was legal advisor to Burgess.

Patient Accountability Platform

Founded in 1997, Burgess operates at the intersection
of healthcare, finance and technology. The company helps leading American
health insurers and ACOs set a new standard: Payment Accountability. The
company’s cloud-based platform, Burgess Source, is the only solution that
natively brings together up-to-date regulatory data, claims pricing and
editing, and real-time analytics tools. This unified approach allows clients to
make payments with total confidence, and make business decisions with real
intelligence.

Strategic Fit for HealthEdge to Power Next-Generation
Payor Technology

“The acquisition of Burgess is a great strategic fit for HealthEdge to enter the large, high-growth market of payment integrity, helping address the estimated $1 trillion in wasteful spending in the U.S. healthcare system. This partnership will extend HealthEdge’s best-in-class claims processing to include software-driven payment integrity, actioned before a claim is paid, delivering significant value to health plans beyond what is available in the market today,” said Ram Jagannath, Global Head of Healthcare for Blackstone Growth and Chairman of HealthEdge.  “We are excited to invest further in HealthEdge to continue building a market-leading software platform for health insurers.” 

HealthEdge provides
mission-critical next-generation Core Administrative Processing Systems
solutions to healthcare payors, enabling them to administer benefits, configure
plans, manage providers, and enroll participants seamlessly and efficiently.
The company’s products offer a modern, simple user interface, greater
flexibility, and a cloud-compliant solution well suited to the increasingly
complex and data-rich healthcare environment.

HealthEdge’s acquisition of Burgess follows the acquisition of a
majority stake in HealthEdge by funds managed by Blackstone (“Blackstone”) in
April 2020.