Category Archives: News

SILENT IMPRESSIONS

Every encounter we have with another person or a business results in an impression. An encounter may be conversation, email, voicemail, text, social media, appearance, hygiene and others. Some of the impressions we form based on these encounters are stronger than others and because people are all different, reactions vary. Some impressions are indelible and others can be replaced by subsequent impressions. Every impression formed by a person, either positive or negative, can be called a “moment of truth”.

However in any case, impressions are actionable in terms of future decision making, willingness to start/continue a relationship, buying services and drawing comparisons to other people and/or businesses. When impressions are favorable, the likelihood of a continued relationship increases and the opportunity to strengthen such a relationship is available.

The problem is that when they are negative, we rarely know about it – ergo “silent impressions”. Business potential and new friendships are blocked by the negative impressions that have been formed. Worse yet, these impressions are often shared with others who then form their own impressions based on hear-say.

The Impact of Healthcare RCM on Your Brand

As leaders in healthcare revenue cycle management, we have responsibility for millions of these “moments of truth” every day. Every patient encounter, phone call, visit, email and snail mail represents an opportunity for a patient, visitor or family member to form an impression.

Same goes for the physical appearance of the hospital facility and work areas.  However, the presentation of our bills to payors and patients is a big part of the revenue cycle work product and “silent impressions” formed about those items can result in disregard that leads to the electronic (or hard copy) trash can instead of your lockbox. Of course, you have reports and data designed to alert you to claims denials, trends and edits etc. – all good. However, if you are relying too much on external feedback to evaluate the efficacy of billing or other functions, just remember that those “silent impressions” are out there and you will not likely hear about them.

I have blogged before about the value of conducting a “moment of truth” audit in your hospital. I would be very interested to hear of the results if you have. If you have not and would like to talk about methodology and the benefits, please contact me online or give me a call at 888-646-1330.

Posted By: nearterm-admin

Improving Denial Management in Healthcare & Medical Billing

denial management in healthcare

When insurers deny medical claims, it takes a bite out of your revenue every year. Nationwide, this annual loss amounts to $262 billion, according to Modern Healthcare.

As a matter of fact, insurers deny an average of 9 percent of claims overall, which means that your staff is engaged in a continual process of managing and appealing to collect on patient bills. While hospitals do eventually manage to collect 63 percent of the amount of denied claims, the denial management process costs an average of $118 per claim — not to mention the loss of time from other operating tasks.

Furthermore, you stand to lose more than just the dollar amount of your medical accounts receivable due to denied claims. When your claims denial management system attempts to collect the unpaid amounts from patients, you’ll alienate those patients and affect your brand reputation. Here’s a brief overview of the medical denial management process and the best-practice steps you can take in mitigating your losses.

What Are the Most Common Reasons for Claim Denials?

Each health organization is different, and the causes for claim denials will vary depending on the situation. Here are the top reasons:

  • Invalid subscriber information: This can be due to expired policy information or errors introduced by manual entry of patient names or ID numbers.
  • Non-covered services: The list of allowed services associated with each specific diagnosis by each insurance company are in a state of near-constant flux.
  • Coding errors: These include improper use of modifiers or inaccurate reporting of bundled services.
  • Timing errors: Failure to submit claims in a timely manner, or to obtain pre-authorization.
  • Pre-existing conditions: These are any conditions present before the policy was purchased.

Steps to Managing Claim Denials

The following steps can strengthen your hospital denial management system and also reduce the number of future denied claims:

1. Teach Your Patients How to Solve the Issue

In this way, you align your hospital with patients’ financial interests, and communicate the fact that you’re on the patient’s side. Patients and their families are stressed and often have no understanding of the insurance denial system. You can be their resource while also protecting your own bottom line.

2. Track Your Denials

In a busy hospital, claims denials can get sidelined and misplaced. When you install a system that keeps track of every denied claim, you’ll be able to see where problems arise. You’ll also increase your revenue because claims revenue won’t disappear.

3. Keep Your Appeals on Schedule

The process of tracking your denials includes a clear timeline. Insurance companies set appeal deadlines for hospitals, so those dates must be integrated into your medical billing denial management process.

4. Identify Reasons for Successes and Failures

Every hospital copes with unpaid claims. When you are transparent about this process, you can use analytics to learn the reasons behind claim denials and why they are or are not successfully followed up in your system. You can also track denial trends. Armed with this information, you can predict the most effective tactics and strengthen your process in the future.

5. Consider an Outsourced Solution

It is often most cost-effective to rely on the services of denial claims experts, rather than training your staff to track and appeal each denial. Denial management professionals have the time and dedication to learn how to negotiate with insurers and to understand the context behind each individual denial. When you find an outsourced claims denial solution that also provides a high level of customer satisfaction and responsiveness, you and your staff will have more time and energy to focus on other aspects of running your hospital.

The right professional approach to managing claim denials can make the critical difference in building your long-term financial viability. Contact our expert team to learn more about how you can leverage our healthcare revenue cycle management services to reduce your claims denial losses.

Posted By: nearterm-admin

Revenue Integrity & Capture – Who’s Herding the Cats?

Cross functional processes can be difficult to manage in hospitals. One reason pertinent to Revenue Integrity is that typically, the organization structure is a series of vertical disciplines with differently defined focus (HIM, PFS, PATIENT ACCESS, ANCILLARY DEPARTMENTS, MD’s, et.al.). This structure can be and is very effective in many hospitals. However, revenue integrity management doesn’t always “fit”. It requires that all of these disciplines (a) agree on work definition, (b) have consistent education addressing CDM changes, compliance matters and related topics, (c) have the tools in place to manage their performance (d) are clear on current state and change opportunities that require attention (e) communicate routinely specifically about Revenue Integrity matters.

We all know the obvious – if revenue is not captured, coded and billed correctly we risk HIPAA violation consequences, cash flow, cost associated with denials and duplicate handling of work, patient satisfaction and P&L impact. So in an environment where cross functional processing challenges exist and the expressed risks are critical, “WHO’S HERDING THE CATS” in your organization to ascertain that you are banking every dollar that is coming to you? Who in your organization is charged to remain contemporary on what you can bill for and what you cannot bill for and related implementations as change occurs? Is that responsibility spread among various stakeholders and if so, do all disciplines in the revenue capture continuum agree or is there a need for conflict resolution – who identifies and handles that? Who is the leader?

Some hospitals have a staff position designated to lead the revenue integrity charge. In order to be effective, this role must be defined such that it carries authority that crosses organization lines. Other hospitals have established a committee or team consisting of representation from key stakeholders. The committee or team is usually lead by the CFO, VP Revenue Cycle or COO. Either structure or even some hybrid can be effective.

However, many hospitals have not embraced this field with a well-defined multidisciplinary plan that has a specific function as part of the organization. When we are asked to consult with those hospitals about revenue issues, it is usually because they are experiencing symptoms like inordinate denials, decline in same-store revenue, cash flow issues and sometimes conflict regarding coding policy. Our initial discovery work is designed to identify current state, confirm those “symptoms” and address what has caused them. As a result, we can introduce early wins and sometimes interim leadership but the more strategic solution often requires organization change that establishes Revenue Integrity discipline and accountability. It is rewarding to facilitate and see transformation in Revenue Integrity practices at hospitals that previously focused more on symptoms than development of a strategic approach.

If you are working on charge capture, CDM or another component of Revenue Integrity and have questions or if you have in place relevant best practices you are willing to share, please post to this BLOG so that others can benefit. Our healthcare management consulting experts are always available to answer questions or assist you regardless of where you are on the path leading to Revenue Integrity.

Posted By: nearterm-admin

Revenue Cycle Processing Backlogs Are Not “NORMAL”. It’s time to raise the bar – eliminate BACKLOG TOLERANCE!

I talk every week with Revenue Cycle Leaders from all types of hospitals around the country. When I ask how things are going, there are many common responses that reflect current concerns and challenges they are facing. These include conversion issues, staffing constraints, volume fluctuation, talent acquisition/retention, cooperation among stakeholders, change in payor practices and training, just to name a few. Here are some recent quotes that typify their remarks:

“We are preparing for a conversion. The training and build distractions have resulted in backlogs and performance decline. After the new system is implemented, there will be a learning curve and modifications to make for the new system to do what it is purported to do.”

“Budget constraints require me to do more with less every year. This year, we are struggling to keep up with processing volumes, especially billing and follow-up. We are getting behind. Our aging looks awful.”

“Our Revenue Cycle Team is great but it seems like every day we learn of new HIPAA and other rules imposed on us that require change, training and personnel shifts. For example, we have about 12 days of DNFB and can’t seem to get a handle on it. Chart assembly and completion are also behind. If we can’t get it coded on time, we can’t bill and collect on time. But it’s been that way for some time now so nothing new.”

“Denials are killing us! We have done some analysis to determine root causes and we have a feel for that but we just don’t have the resources to address those causes. We devote our existing FTE’s to working current volumes but the denial backlog is growing and it is a real problem for us. Not only are we not getting paid by insurance and Medicare, but patients complain, citing that we are to blame so until the denials are resolved, they are reluctant to pay patient liabilities like deductibles and coinsurance.”

“We are doing OK. We have backlogs in various areas but we know that we are in a community with a limited talent/labor pool so we are always working hard to balance make or buy decisions. Our days, DNFB and denials are higher than facilities in other communities but we just don’t have the technology or budget to compete with their benchmarks.”

Identify and Eliminate BACKLOG TOLERANCE

You get the picture. We have developed what I call BACKLOG TOLERANCE. We know backlogs exist and can usually identify why, but we just can’t seem to address the root causes effectively. Furthermore, we can’t eliminate the backlogs and sustain current processing designed to prevent recurrence. Instead, we often change the standard.

eliminate backlog

This condition would not be acceptable in other industries and in my opinion; it should not be tolerated in ours. Sure, every business experiences episodic conditions that result in temporary backlogs from time to time – understandable. But when they do, they scramble immediately to meet the problem head-on and take definitive steps to resolve the issue. They implement the technology, invest the human capital and embrace preventive design aimed at making sure the backlog was in fact temporary, and not a permanent “NEW NORMAL.”

Of course, many hospitals have been very progressive and certainly are not tolerant of backlogs. They proactively anticipate influences that might result in processing challenges and they reinvent their organizations well ahead of impact. I always learn from them and have great admiration for their approach, vigilance, creativity and the leadership they have in place that enables their success.

If you can relate to my comments, I would love to hear from you. If you are in a hospital with some degree of BACKLOG TOLERANCE, I would welcome an opportunity to talk with you about solutions you are working on that might help others. If you have “recovered” from “BACKLOG TOLERANCE DISORDER” (Is there a code for that?), please share your plight – I am sure your colleagues would appreciate hearing ideas that might be helpful to them.

Posted By: nearterm-admin
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