Physicians achieving Better ROI with Claim Status Checking

A vital undertaking of any medical facility large or small – independent or outpatient is to track or check the claim status of a patient’s health cover. With having the knowledge of the claim status many healthcare units face revenue leakages, which in turn pushes them towards winding up their businesses (healthcare facility).

How can Physicians achieve better ROI with claim status checking?

You as a physician are busy, the staff is caught up, but staying on top of claims statuses is as important, as checking the patients. Proactively monitoring can keep small issues from turning into claim denials. As a matter of fact, it takes around 5-12 minutes per claim to check status manually and that adds up fast. Most of the time, the healthcare staff spends more energy only to find that the claims in question don’t have a status yet.

A tremendous amount of time is wasted by revenue cycle management experts checking on claims where nothing has happened yet. A technology-driven, automated approach to claim status checking/monitoring ensures resources are being expended where they will do the most good, which is working only those claims that have already been identified as having issues. Medical billing and coding companies are your go-to man in such a scenario if you feel the in-house department has other issues to take care of.

In this changing climate, revenue must be managed differently to ensure that the value delivered to patients is reimbursed appropriately both in terms of accuracy and timeliness.

Understand claims with the context of revenue cycle management

For hospitals and doctor’s offices to ensure that their claims are paid, they must first understand how the different components of claims management affect compensation.

Whether you call it revenue cycle or protecting your reimbursement, success will depend on making many improvements simultaneously. It’s not just one small thing that you fix, but making several improvements and making them simultaneously through the process from pre-care to zero balance.

The negative impact improper claims status tracking can have on reimbursement are significantly more pronounced in clinical settings where resources dedicated solely to the revenue cycle are often lacking.

Healthcare experts working over claims management realized it early on that physicians are running the business, but they are not businessmen. They are caregivers, but still they have to manage their practice as a business and claims processing and management was the sand in the gears of practice management.

According to experts, those healthcare organizations and providers succeeding at reimbursement take into account and address how each of the variable components of the patient-provider interaction fit into the revenue cycle and could introduce gaps leading to loss or risk:

Here are some points to ponder upon:

  1. Pre-service (pre-registration, pre-authorization)
  2. Process of care
  3. Process integrity practices (chargemaster, coding compliance, clinical documentation)
  4. Medical Billing Services (customer support, collections, and follow-up)
  5. Administrative services (contract management, fee schedules, debt collections, managed care contracts, denial management)

When you classify your practice or your hospital across these five areas you are then able to address within each of these components – what is working and not working – what are the industry standards –  where are your peers compared to where you are, and lastly what you need to do to get to the next stage and then beyond that.

In simple terms, refining reimbursements begins with assessing the current state of affairs. Experts recommend that physician practices and hospitals pay special attention to three broad functional areas, which are financial, technical, and operational.

Keep an eye open for payer rules and denial rate calculations for a positive ROI

The first step to better the ROI is identifying denials and the reasons behind them. However, saving important claim denial statistics may not be as easy as plugging numbers into a formula.

This is because providers may not have access to claims denial data from payers. Payers many a time are tentative to release the data, especially how often they reject claims, because of competition. They tend to keep the information secluded or restricted to prevent potential customers from passing them up for a payer with a lower denial rate.

As a result, industry averages for claims denial rates generally differ from one report to another. For example, a private sampling agency might report that the denial average overall is between 5 percent and 10 percent, whereas the Government Accountability Office (GAO) found that up to one-quarter of claims are denied.

Do remember that Claims status checking/tracking and medical billing teams not only draw data from across the healthcare organization, but they must also manage different payer rules and medical codes. Using manual processes could slow productivity given the plethora of data needed to successfully manage denials. So go for automated tools.